Ureteral Calculi

Ureteral Calculi
EAU/AUA Nephrolithiasis Guideline Panel

Members:
Glenn M. Preminger, M.D., Co-Chair
Hans-Gran Tiselius, M.D., Ph.D., Co-Chair
Dean G. Assimos, M.D., Vice Chair
Peter Alken, M.D., Ph.D.
A. Colin Buck, M.D., Ph.D.
Michele Gallucci, M.D., Ph.D.
Thomas Knoll, M.D., Ph.D.
James E. Lingeman, M.D.
Stephen Y. Nakada, M.D.
Margaret Sue Pearle, M.D., Ph.D.
Kemal Sarica, M.D., Ph.D.
Christian Trk, M.D., Ph.D.
J. Stuart Wolf, Jr., M.D.
Consultants:
Hanan S. Bell, Ph.D.
Patrick M. Florer
AUA and EAU Staff:
Gunnar Aus, M.D., Ph.D., EAU Guidelines Office Chair
Heddy Hubbard, Ph.D.
Edith Budd
Karin Plass
Michael Folmer
Katherine Moore
Kadiatu Kebe
MedicalWriting Assistance:
Diann Glickman, PharmD
2007 Guideline for the

Management of Ureteral Calculi
Chapter 1: The Management of Ureteral Calculi: Diagnosis and

Treatment Recommendations
Table of Contents
Introduction..................................................................................................................................... 3
Methodology ................................................................................................................................... 4
Results of the Outcomes Analysis ................................................................................................ 12
Observation and Medical Therapies ......................................................................................... 12
Shock-wave Lithotripsy and Ureteroscopy............................................................................... 13
Efficacy Outcomes.................................................................................................................... 15
Procedure Counts...................................................................................................................... 22
Complications ........................................................................................................................... 27
Other Surgical Interventions..................................................................................................... 30
The Index Patient .......................................................................................................................... 30
Treatment Guidelines for the Index Patient .................................................................................. 31
For All Index Patients ............................................................................................................... 31
For Ureteral Stones <10 mm..................................................................................................... 31
For Ureteral Stones >10 mm..................................................................................................... 33
For Patients Requiring Stone Removal..................................................................................... 34
Recommendations for the Pediatric Patient.............................................................................. 36
Recommendations for the Nonindex Patient ............................................................................ 37
Discussion ..................................................................................................................................... 37
Medical Expulsive Therapy ...................................................................................................... 38
Shock-wave Lithotripsy............................................................................................................ 39
Copyright 2007 American Urological Association Education and Research, Inc. and
European Association of Urology
Ureteroscopy............................................................................................................................. 42
Percutaneous Antegrade Ureteroscopy..................................................................................... 44
Laparoscopic and Open Stone Surgery..................................................................................... 45
Special Considerations.............................................................................................................. 46
Pregnancy ................................................................................................................. 46
Pediatrics .................................................................................................................. 47
Cystine Stones ........................................................................................................... 48
Uric acid Stones ........................................................................................................ 49
Research and Future Directions .................................................................................................... 49
Introduction
The American Urological Association (AUA) Nephrolithiasis Clinical Guideline
Panel was established in 1991. Since that time, the Panel has developed three guidelines
on the management of nephrolithiasis, the most recent being a 2005 update of the original
1994 Report on the Management of Staghorn Calculi.1 The European Association of
Urology (EAU) began their nephrolithiasis guideline project in 2000, yielding the
publication of Guidelines on Urolithiasis, with updates in 2001 and 2006.2 While both
documents provide useful recommendations on the management of ureteral calculi,
changes in shock-wave lithotripsy (SWL) technology, endoscope design, intracorporeal
lithotripsy techniques, and laparoscopic expertise have burgeoned over the past five to
ten years.
Under the sage leadership of the late Dr. Joseph W. Segura, the AUA Practice
Guidelines Committee suggested to both the AUA and the EAU that they join efforts in
developing the first set of internationally endorsed guidelines focusing on the changes
introduced in ureteral stone management over the last decade. We therefore dedicate this
report to the memory of Dr. Joseph W. Segura whose vision, integrity, and perseverance
led to the establishment of the first international guideline project.
This joint EAU/AUA Nephrolithiasis Guideline Panel (hereinafter the Panel)
performed a systematic review of the English language literature published since 1997
and a comprehensively analyzed outcomes data from the identified studies.
Based on their findings, the Panel concluded that when removal becomes
necessary, SWL and ureteroscopy (URS) remain the two primary treatment modalities for
the management of symptomatic ureteral calculi. Other treatments were reviewed,

including medical expulsive therapy (MET) to facilitate spontaneous stone passage,
percutaneous antegrade ureteroscopy, and laparoscopic and open surgical
ureterolithotomy. In concurrence with the previously published guidelines of both
organizations, open stone surgery is still considered a secondary treatment option. Blind
basketing of ureteral calculi is not recommended. In addition, the Panel was able to
provide some guidance regarding the management of pediatric patients with ureteral
calculi. The Panel recognizes that some of the treatment modalities or procedures
recommended in this document require access to modern equipment or presupposes a
level of training and expertise not available to practitioners in many clinical centers.
Those situations may require physicians and patients to resort to treatment alternatives.
This article will be published simultaneously in European Urology and The
Journal of Urology. The Panel believes that future collaboration between the EAU and
the AUA will serve to establish other internationally approved guidelines, offering
physician and patient guidance worldwide.
Methodology
The Panel initially discussed the scope of the guideline and the methodology,
which would be similar to that used in developing the previous AUA guideline. All
treatments commonly employed in the United States and/or Europe were included in this
report except for those that were explicitly excluded in the previous guideline or newer
treatments for which insufficient literature existed. In the analysis, patient data were
stratified by age (adult versus child), stone size, stone location, and stone composition.
Later, however, the data were found to be insufficient to allow analysis by composition.
The outcomes deemed by the Panel to be of particular interest to the patient included the
following: stone-free rate, number of procedures performed, stone-passage rate or
probability of spontaneous passage, and complications of treatment. The Panel did not
examine economic effects, including treatment costs.
Outcomes were stratified by stone location (proximal, mid, and distal ureter) and
by stone size (dichotomized as 10 mm and >10 mm for surgical interventions, and 5
mm and >5 mm for medical interventions and observation where possible; exceptions
were made when data were reported, for example as <10 mm and 10 mm). The mid
ureter is the part of the ureter that overlies the bony pelvis, i.e., the position of the ureter
that corresponds to the sacroiliac joint; the proximal ureter is above and the distal ureter
is below. Treatments were divided into three broad groups:
1. Observation and medical therapy
2. Shock-wave lithotripsy and ureteroscopy
3. Open surgery, laparoscopic stone removal, or percutaneous antegrade
ureteroscopy.
The review of the evidence began with a literature search and data extraction.
Articles were selected from a database of papers derived from MEDLINE searches
dealing with all forms of urinary tract stones. This database was maintained by a Panel
chair. The abstract of each paper was independently reviewed by an American and a
European Panel member, and articles were selected for data extraction if any panel
member felt it might have useful data. Additional articles were suggested by Panel
members or found as references in review articles. In total, 348 citations entered the
extraction process. An American and a European Panel member each independently

extracted data from each article onto a standardized form. The team members reconciled
the extractions, and the data were entered into a Microsoft Access (Microsoft,
Redmond, WA) database. The Panel scrutinized the entries, reconciled the
inconsistencies in recording, corrected the extraction errors, and excluded some articles
from further analysis for the following reasons:
1. The article was included in the previous guideline.
2. The article did not provide usable data on the outcomes of interest.
3. Results for patients with ureteral stones could not be separated from results for
those with renal stones.
4. The treatments used were not current or were not the focus of the analysis.
5. The article was a review article of data reported elsewhere.
6. The article dealt only with salvage therapy.
A total of 244 of the 348 articles initially selected had extractable data. Articles
excluded from evidence combination remained candidates for discussion in the text of the
guideline.
The goal was to generate outcomes tables comparing estimates of outcomes
across treatment modalities. To generate an outcomes table, estimates of the probabilities
and/or magnitudes of the outcomes are required for each intervention. Ideally, these are
derived from a synthesis or combination of the evidence. Such a combination can be
performed in a variety of ways depending on the nature and quality of the evidence. For
this report, the Panel elected to use the Confidence Profile Method3, which provides
methods for analyzing data from studies that are not randomized controlled trials (RCTs).
The Fast*Pro computer software4 was used in the analysis. This program provides
posterior distributions from meta-analyses from which the median can be used as a best
estimate, and the central 95% of the distribution serves as a confidence interval (CI).
Statistical significance at the p<0.05 level (two-tailed) was inferred when zero was not
included in the CI.
Because of the paucity of controlled trials found on literature review, however,
the outcome for each intervention was estimated by combining single arms from various
clinical series. These clinical series frequently had very different outcomes, likely due to
a combination of site-to-site variations in patient populations, in the performance of the
intervention, in the skill of those performing the intervention, and different methods of
determining stone-free status. Given these differences, a random-effects, or hierarchical,
model was used to combine the studies.
Evidence from the studies meeting the inclusion criteria and reporting a given
outcome was combined within each treatment modality. Graphs showing the results for
each modality were developed to demonstrate similarities and differences between
treatments.
The available data for procedures per patient would not permit a statistical
analysis using these techniques. Unlike the binary outcome of stone-free status (the
patient either is or is not stone free), the number of procedures per patient is a discrete
rate. In some cases discrete rates can be approximated with a continuous rate, but in order
to meta-analyze continuous rates, a measure of variance (e.g., standard deviation,
standard error) is needed in addition to the mean. Unfortunately, measures of variance
were rarely reported in the studies reviewed. As a result, numbers of procedures per
patient were evaluated by calculating the average across studies weighted by the number
of patients in each study. Procedures per patient were counted in three totals: primary
procedures, secondary procedures, and adjunctive procedures. Primary procedures were
all consecutive procedures of the same type aimed at removing the stone. Secondary
procedures were all other procedures used to remove the stone. Adjunctive procedures
were defined as additional procedures that do not involve active stone removal. One
difficulty in estimating the total number of procedures per patient is that secondary and
adjunctive procedures were not reported consistently. Since the Panel had decided to
analyze primary, secondary, and adjunctive procedures separately, only studies that
specifically reported data on a type of procedure were included in estimates for that
procedure type. This approach may have overestimated numbers of secondary and
adjunctive procedures because some articles may not have reported that procedures were
not performed.
It is important to note that, for certain outcomes, more data were reported for one
or another treatment modality. While resulting CIs reflect available data, the probabilities
for certain outcomes can vary widely within one treatment modality. In addition, the fact
that data from only a few RCTs could be evaluated may have somewhat biased results.
For example, differences in patient selection may have had more weight in analyses than
differing treatment effects. Nevertheless, the results obtained reflect the best outcome
estimates presently available.
Studies that reported numbers of patients who were stone free after primary
procedures were included in the stone-free analysis. Studies that reported only the
combined number of patients who either were stone free or had clinically insignificant
fragments were excluded. Many studies did not indicate how or when stone-free status
was determined. The stone-free rate was considered at three time points: after the first
procedure, after all consecutive procedures using the primary treatment, and after the
total treatments.
Initially, the Panel divided complications into three broad categories: acute, longterm, and medical; however, after examining the available evidence, the Panel
determined that this breakdown was not useful. Several factors caused inaccuracy in the
estimates, but did so in opposite directions, thereby reducing the magnitude of
inaccuracy. For example, including studies that did not specifically mention that there
were no occurrences of a specific complication may have led to overestimates of
complication rates when meta-analyzed. By combining similar complications, the Panel
also potentially mitigated the overestimate by making it more likely that a complication
in the class was reported. The probability that a patient will have a complication may
still be overstated slightly because some patients experienced multiple complications.
Since the grouping of complications varies by study, the result of the meta-analysis is
best interpreted as the mean number of complications that a patient may experience rather
than as the probability of having a complication. Moreover, since reporting of
complications is not consistent, the estimated rates given here are probably less accurate
than the CIs would indicate. There were insufficient data to permit meaningful metaanalyses of patient deaths.
Data analyses were conducted for two age groups. One analysis included studies
of patients ages 18 or younger (or identified as pediatric patients in the article without
specifying age ranges). The adult analysis included all other studies even if children were
included.
After the evidence was combined and outcome tables were produced, the Panel
met to review the results and identify anomalies. From the evidence in the outcome tables
and expert opinion, the Panel drafted the treatment guidelines.
In this guideline the standard, recommendations, and options given were rated
according to the levels of evidence published from the U.S. Department of Health and
Human Services, Public Health Service, Agency for Health Care Policy and Research:5
Ia.
Evidence obtained from meta-analysis of randomized trials
Ib.
Evidence obtained from at least one randomized trial
IIa.
Evidence obtained from at least one well-designed controlled study

without randomization
IIb.
Evidence obtained from at least one other type of well-designed quasiexperimental study
III.
Evidence obtained from well-designed nonexperimental studies, such as

comparative studies, correlation studies, and case reports
IV.
Evidence obtained from expert committee reports, or opinions, or clinical

experience of respected authorities
As in the previous AUA guideline, the present statements are graded with respect
to the degree of flexibility in application. Although the terminology has changed slightly,
from the original AUA reports, the current three levels are essentially the same. A
"standard" is the most rigid treatment policy. A "recommendation" has significantly less
10
rigidity, and an "option" has the largest amount of flexibility. These terms are defined as
follows:
1.
Standard: A guideline statement is a standard if: (1) the health outcomes of

the alternative interventions are sufficiently well known to permit meaningful
decisions, and (2) there is virtual unanimity about which intervention is
preferred.
2.
Recommendation: A guideline statement is a recommendation if: (1) the

health outcomes of the alternative interventions are sufficiently well known
to permit meaningful decisions, and (2) an appreciable, but not unanimous
majority agrees on which intervention is preferred.
3.
Option: A guideline statement is an option if: (1) the health outcomes of the
interventions are not sufficiently well known to permit meaningful decisions,
or (2) preferences are unknown or equivocal.
The draft was sent to 81 peer reviewers of whom 26 provided comments; the
Panel revised the document based on the comments received. The guideline was
submitted first for approval to the Practice Guidelines Committee of the AUA and the
Guidelines Office of the EAU and then forwarded to the AUA Board of Directors and the
EAU Board for final approval.
The guideline is posted on the American Urological Association website,
www.auanet.org, and on the European Association of Urology website,
www.uroweb.org. Chapter 1 will be published in The Journal of Urology and in
European Urology.
11
Results of the Outcomes Analysis

The results of the analysis described in this chapter provide most of the
evidentiary basis for the guideline statements. Further details and tables corresponding to
the figures in this section are found in Chapter 3 and the Appendixes.
The panels attempt to differentiate results for pediatric patients from those for
adults was not completely successful as most studies included both adults and children.
Where possible, the panel performed two analyses, one including all studies regardless of
patient age, and a second including only those studies or groups of patients that were
comprised entirely of pediatric patients.
Observation and Medical Therapies

Stone-passage rates
Only limited data were found on the topic of spontaneous passage by stone size.
For stones 5 mm, meta-analysis of five patient groups (224 patients) yielded an estimate
that 68% would pass spontaneously (95% CI: 46% to 85%]. For stones >5 mm and 10
mm, analysis of three groups (104 patients) yielded an estimate that 47% would pass
spontaneously (95% CI: 36% to 59%). Details of the meta-analysis are presented in
Appendixes 8 and 9.
Two medical therapies had sufficient analyzable data: the calcium channel
blocker nifedipine and alpha-receptor antagonists. Analyses of stone-passage rates were
done in three ways. The first combined all single arms evaluating the therapies. Using
this approach, meta-analysis of four studies of nifedipine (160 patients) yielded an
estimate of a 75% passage rate (95% CI: 63% to 84%). Six studies examined alpha
12
blockers (280 patients); the meta-analysis yielded a stone-passage rate of 81% (95% CI:
72% to 88%).
The second method was a standard Bayesian hierarchical meta-analysis of the
available RCTs that compared either nifedipine or alpha blockers to control therapies.
The results for nifedipine showed an absolute increase of 9% in stone-passage rates (95%
CI: -7% to 25%), which was not statistically significant. Meta-analysis of alpha blockers
versus control showed an absolute increase of 29% in the stone-passage rate (95% CI:
20% to 37%), which was statistically significant.
The Panel also attempted to determine whether alpha blockers provide superior
stone passage when compared to nifedipine. Two randomized controlled trials were
identified. When hierarchical meta-analysis was performed on these two studies,
tamsulosin provided an absolute increase in stone-passage rate of 14% (95% CI: -4% to
32%) which was not statistically significant. When nonhierarchical methods were used,
the stone-passage improvement increased to 16% (95% CI: 7% to 26%) which was
statistically significant. Finally, the Panel used the results of the meta-analyses versus
controls (second method above) to determine the difference between alpha blockers and
calcium channel blockers. This method allows the use of more data but is risky since it
depends on the control groups having comparable results. The analysis yielded a 20%
improvement in stone-passage rates with alpha blockers, and the 95% CI of 1% to 37%
just reached statistical significance.
Shock-wave Lithotripsy and Ureteroscopy

Stone-free rates were analyzed for a number of variant methods of performing
SWL and URS. The Panel attempted to differentiate between bypass, pushback, and in
13
situ SWL as well as differences between lithotripters. Most differences were minimal and
did not reach statistical significance. For that reason, the data presented in this Chapter
compare the meta-analysis of all forms of SWL to the meta-analysis of all forms of URS.
The Panel also attempted to differentiate between flexible and rigid ureteroscopes.
Details of the breakdowns by type of SWL and URS are given in Chapter 3. Data were
analyzed for both efficacy and complications. Two efficacy outcomes were analyzed:
stone-free rate and procedure counts. Complications were grouped into classes. The most
important classes are reported herein. The full complication results are in Appendix 10.
Analyses were performed for the following patient groups where data were
available.
1. Proximal stones 10 mm
2. Proximal stones >10 mm
3. Proximal stones regardless of size
4. Mid-ureteral stones 10 mm
5. Mid-ureteral stones >10 mm
6. Mid-ureteral stones regardless of size
7. Distal stones 10 mm
8. Distal stones >10 mm
9. Distal stones regardless of size
Analyses of pediatric groups were attempted for the same nine groups, although
data were lacking for many groups.
14
Efficacy Outcomes
Stone-free rates
The Panel decided to analyze a single stone-free rate. If the study reported the
stone-free rate after all primary procedures, that number was used. If not and the study
reported the stone-free rate after the first procedure, then that number was used. The
intention of the Panel was to provide an estimate of the number of primary procedures
and the stone-free rate after those procedures. There is a lack of uniformity in the
literature in reporting the time to stone-free status, thereby limiting the ability to
comment on the timing of this parameter.
The results of the meta-analysis of stone-free data are presented for the overall
group in Table 1 and Figure 1. The results are presented as medians of the posterior
distribution (best central estimate) with 95% Bayesian CIs (credible intervals [CIs]).
15
Table 1. Stone-Free Rates for SWL and URS in the Overall Population
16
Figure 1. Stone-Free Rates for SWL and URS in the Overall Population
Stone Free Rates after Primary/First Treatment
Distal Ureter - SWL

Distal Ureter - URS
Distal Ureter < 10 mm - SWL
Distal Ureter < 10 mm - URS
Distal Ureter > 10 mm - SWL
Distal Ureter > 10 mm - URS
Mid Ureter - SWL
Mid Ureter - URS
Mid Ureter < 10 mm - SWL
Mid Ureter < 10 mm - URS
Mid Ureter > 10 mm - SWL
Mid Ureter > 10 mm - URS
Proximal Ureter - SWL
Proximal Ureter - URS
Proximal Ureter < 10 mm - SWL
Proximal Ureter < 10 mm - URS
Proximal Ureter > 10 mm - SWL
Proximal Ureter > 10 mm - URS
0%
20%
40%
60%
80%
100%
Estimated Occurrence Rate with 95% CI

CI=confidence interval
17
This analysis shows that overall, for stones in the proximal ureter (n=8,670), there
was no difference in stone-free rates between SWL and URS. However, for proximal
ureteral stones <10 mm (n=1,129), SWL had a higher stone-free rate than URS, and for
stones >10 mm (n=523), URS had superior stone-free rates. This difference arises
because the stone-free rate for proximal ureteral stones treated with URS did not vary
significantly with size, whereas the stone-free rate following SWL negatively correlated
with stone size. For all distal stones, URS yields better stone-free rates overall and in
both size categories. For all mid-ureteral stones, URS appears superior, but the small
number of patients may have prevented results from reaching statistical significance.
Unfortunately, RCTs comparing these treatments were generally lacking, making
an accurate assessment impossible. However, the posterior distributions resulting from
the meta-analysis can be subtracted, yielding a distribution for the difference between the
treatments. If the CI of this result does not include zero, then the results may be
considered to be statistically significantly different. This operation is mathematically
justifiable but operationally risky: if the patients receiving different treatments are
different or if outcome measures are different, results may be meaningless. Nonetheless,
the Panel performed the comparison and found that URS stone-free rates were
significantly better than SWL rates for distal ureteral stones 10 mm and >10 mm and for
proximal ureteral stones >10 mm. The stone-free rate for mid-ureteral stones was not
statistically significantly different between URS and SWL. The results with URS using a
flexible ureteroscope for proximal ureteral stones appear better than those achieved with
a rigid device, but not at a statistically significant level.
18
Stone-free results for pediatric patients are shown in Table 2 and Figure 2. The
very small number of patients in most groups, particularly for URS, makes comparisons
among treatments difficult. However, it does appear that SWL may be more effective in
the pediatric subset than in the overall population, particularly in the mid and lower
ureter.
19
Table 2. Stone-Free Rates for SWL and URS, Pediatric Population
20
Figure 2. Stone-Free Rates for SWL and URS, Pediatric Population
Stone Free Rates after Primary/First Treatment

Pediatric Patients
Distal Ureter - SWL

Distal Ureter - URS
Mid Ureter - SWL
Mid Ureter - URS
0%
20%
40%
60%
80%
100%

CI=confidence interval
21
Procedure Counts
Procedure counts were captured as three types:
1. Primary procedures the number of times the intended procedure was
performed.
2. Secondary procedures the number of times an alternative stone removal
procedure(s) was performed.
3. Adjunctive procedures additional procedures performed at a time other than
when the primary or secondary procedures were performed; these could
include procedures related to the primary/secondary procedures such as stent
removals as well as procedures performed to deal with complications; most
adjunctive procedures in the data presented represent stent removals. It is
likely that many stent-related adjunctive procedures were underreported, and
thus the adjunctive procedure count may be underestimated.
As mentioned in Chapter 2, it was not possible to perform a meta-analysis or to
test for statistically significant differences between treatments due to the lack of variance
data, and only weighted averages could be computed. The procedure count results for the
overall population are shown in Table 3 and Figure 3. Figure 3 results are presented as
stacked bars.
22
Table 3. Procedure Counts for SWL and URS in the Overall Population
23
Figure 3. Procedure Counts for SWL and URS in the Overall Population
Procedures per Patient
Distal Ureter - SWL

Distal Ureter - URS
Distal Ureter > 10 mm - URS
Mid Ureter - SWL
Mid Ureter - URS
Proximal Ureter > 10 mm - URS
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Weighted Mean Procedures per Patient

Primary Procedures
Secondary Procedures
Adjunctive Procedures
Procedure count results for pediatric patients are shown in Table 4 and Figure 4.
Again, the numbers of patients with available data were small and did not support
meaningful comparisons among treatments.
24
Table 4. Procedure Counts for SWL and URS in the Pediatric Population, All Locations
25
Figure 4. Procedure Counts for SWL and URS in the Pediatric Population, All
Locations
Procedures per Patient - Pediatric Patients
Distal Ureter - SWL

Distal Ureter - URS
Mid Ureter - SWL
Mid Ureter - URS
0.0
0.5
1.0
1.5
2.0
2.5
Weighted Mean Procedures per Patient

Primary Procedures
Secondary Procedures
Adjunctive Procedures
26
Complications
The articles were extracted for various complications; however, the Panel believes
the following are the most relevant:
1. Sepsis
2. Steinstrasse
3. Stricture
4. Ureteral injury
5. Urinary tract infection (UTI)
Serious complications, including death and loss of kidney, were sufficiently rare that data
were not available to estimate their rates of occurrence. Other complications are listed in
Chapter 3.
The complication rates for the overall population by treatment, size, and location
are shown in Table 5.
27
Table 5. Complications Occurrence Rates with SWL and URS, Overall Population
SWL
Groups/Patients Med/95% CI
Distal Ureter
Sepsis
6
2019
3%
(2 - 5)%
Steinstrasse
1
26
4%
(0 - 17)%
Stricture
2
609
Ureteral Injury
UTI
URS
Groups/Patients Med/95% CI
7
1954
2%
(1 - 4)%
0%
(0 - 1)%
16
1911
1%
(1 - 2)%
1
45
1%
(0 - 5)%
23
4529
3%
(3 - 4)%
3
87
4%
(1 - 12)%
3
458
4%
(2 - 7)%
2
398
5%
(0 - 20)%
4
199
4%
(1 - 11)%
Steinstrasse
1
37
8%
(2 - 20)%
Stricture
1
43
1%
(0 - 6)%
7
326
4%
(2 - 7)%
10
514
6%
(3 - 8)%
Mid Ureter
Sepsis
Ureteral Injury
UTI
1
37
6%
(1 - 16)%
1
63
2%
(0 - 7)%
5
704
3%
(2 - 4)%
8
360
4%
(2 - 6)%
Steinstrasse
3
235
5%
(2 - 10)%
1
109
0%
(0 - 2)%
Stricture
2
124
2%
(0 - 8)%
8
987
2%
(1 - 5)%
Ureteral Injury
2
124
2%
(0 - 8)%
10
1005
6%
(3 - 9)%
UTI
5
360
4%
(2 - 7)%
2
224
4%
(1 - 8)%
Proximal Ureter
Sepsis
28
Table 6 summarizes complications for all pediatric groups. Since there are few
groups and patients, it was not possible to stratify data by stone size or location. The
reported frequencies of pain may be inaccurate because of inconsistent reporting.
Table 6. Complication Occurrence Rates - Overall, Pediatric Population
G = number of groups/treatment arms extracted; P = number of patients in those groups.
29
Other Surgical Interventions

Small numbers of studies reported on open surgery, laparoscopic stone removal,
and percutaneous antegrade ureteroscopy. Because these procedures are usually reserved
for special cases, the reported data should not be used to compare procedures with each
other or with SWL or URS. As expected, these more invasive procedures yielded high
stone-free rates when used.
A single pediatric report provided procedure counts for two patients who had one
open procedure each. Two studies reported stone-free rates for children with open
procedures (n=five patients); the computed stone-free rate was 82% (95% CI: 43% to
99%).
The Index Patient

In constructing these guidelines, an index patient was defined to reflect the
typical individual with a ureteral stone whom a urologist treats. The following definition
was created.
The index patient is a nonpregnant adult with a unilateral
noncystine/nonuric acid radiopaque ureteral stone without renal calculi
requiring therapy whose contralateral kidney functions normally and whose
medical condition, body habitus, and anatomy allow any one of the treatment
options to be undertaken.
30
Treatment Guidelines for the Index Patient

For All Index Patients
Standard: Patients with bacteriuria should be treated with appropriate
antibiotics.
[Based on Panel consensus/Level IV]
Untreated bacteriuria can lead to infectious complications and possible urosepsis
if combined with urinary tract obstruction, endourologic manipulation, or SWL. Urine
culture prior to intervention is recommended; screening with dipsticks might be sufficient
in uncomplicated cases.2 In case of suspected or proven infection, appropriate antibiotic
therapy should be administered before intervention.6
Standard: Stone extraction with a basket without endoscopic visualization of
the stone (blind basketing) should not be performed.
Before the availability of modern ureteroscopes, extraction of distal ureteral
stones with a basket with or without fluoroscopy was common. This procedure is,
however, associated with an obvious risk of injury to the ureter. It is the expert opinion of
the Panel that blind stone extraction with a basket should not be performed, and that
intraureteral manipulations with a stone basket should always be performed under direct
ureteroscopic vision. Fluoroscopic imaging of the stone alone is not sufficient.
For Ureteral Stones <10 mm

Option: In a patient who has a newly diagnosed ureteral stone <10 mm and
whose symptoms are controlled, observation with periodic evaluation is an
31
option for initial treatment. Such patients may be offered an appropriate

medical therapy to facilitate stone passage during the observation period.
[Based on review of the data and panel opinion/Level 1A]
The Panel performed a meta-analysis of studies in which spontaneous ureteral
stone passage was assessed. The median probability of stone passage was 68% for stones
5 mm (n=224) and 47% for those >5 and 10 mm (n=104) in size (details previously
discussed and provided in the appendixes). The Panel recognized that these studies had
certain limitations including nonstandardization of the stone size measurement methods
and lack of analysis of stone position, stone-passage history, and time to stone passage in
some. A meta-analysis of MET was also performed which demonstrated that alpha
blockers facilitate stone passage and that the positive impact of nifedipine is marginal.
This analysis also indicates that alpha blockers are superior to nifedipine and, hence, may
be the preferred agents for MET (details provided in the Appendixes). A similar benefit
of MET was demonstrated in a recently published meta-analytic study.7 The methods of
analysis used in this study were somewhat different as the absolute improvement in stone
passage was calculated in our study and the relative improvement in the latter. The vast
majority of the trials analyzed in this and our analysis were limited to patients with distal
ureteral stones. The majority of stones pass spontaneously within four to six weeks. This
was demonstrated by Miller and Kane8, who reported that of stones 2 mm, 2 to 4 mm
and 4 to 6 mm in size, 95% of those which passed did so by 31, 40, and 39 days,
respectively. In a choice between active stone removal and conservative treatment with
MET, it is important to take into account all individual circumstances that may affect
treatment decisions. A prerequisite for MET is that the patient is reasonably comfortable
32
with that therapeutic approach and that there is no obvious advantage of immediate active
stone removal.
Standard: Patients should be counseled on the attendant risks of MET
including associated drug side effects and should be informed that it is
administered for an off label use.
Standard: Patients who elect for an attempt at spontaneous passage or MET
should have well-controlled pain, no clinical evidence of sepsis, and adequate
renal functional reserve.
Standard: Patients should be followed with periodic imaging studies to
monitor stone position and to assess for hydronephrosis.
Standard: Stone removal is indicated in the presence of persistent
obstruction, failure of stone progression, or in the presence of increasing or
unremitting colic.
For Ureteral Stones >10 mm

Although patients with ureteral stones >10 mm could be observed or treated with
MET, in most cases such stones will require surgical treatment. No recommendation can
be made for spontaneous passage (with or without medical therapy) for patients with
large stones.
33
For Patients Requiring Stone Removal

Standard: A patient must be informed about the existing active treatment
modalities, including the relative benefits and risks associated with each
modality.
Specifically, both SWL and URS should be discussed as initial treatment options
for the majority of cases. Regardless of the availability of this equipment and physician
experience, this discussion should include stone-free rates, anesthesia requirements, need
for additional procedures, and associated complications. Patients should be informed that
URS is associated with a better chance of becoming stone free with a single procedure,
but has higher complication rates.
Recommendation: For patients requiring stone removal, both SWL and URS
are acceptable first-line treatments.
[Based on review of the data and Panel consensus/Level 1A-IV (details
provided in Chapter 3)]
The meta-analysis demonstrated that URS yields significantly greater stone-free
rates for the majority of stone stratifications.
Recommendation: Routine stenting is not recommended as part of SWL.
[Based on Panel consensus/Level III]
The 1997 AUA guideline, Report on the Management of Ureteral Calculi, stated
that Routine stenting is not recommended as part of SWL.9 The 1997 guideline Panel
noted that it had become common practice to place a ureteral stent for more efficient
fragmentation of ureteral stones when using SWL. However, the data analyzed showed
34
no improved fragmentation with stenting.9 The current analysis demonstrates similar

findings. In addition, studies assessing the efficacy of SWL treatment with or without
internal stent placement have consistently noted frequent symptoms related to stents.10-13
Option: Stenting following uncomplicated URS is optional.
[Based on Panel consensus/Level 1A]
Several randomized prospective studies published since the 1997 AUA guideline
document have demonstrated that routine stenting after uncomplicated URS may not be
necessary.10, 14-19 It is well documented that ureteral stenting is associated with
bothersome lower urinary tract symptoms and pain that can, albeit temporarily, alter
quality of life.15-17, 20-26 In addition, there are complications associated with ureteral
stenting, including stent migration, urinary tract infection, breakage, encrustation, and
obstruction. Moreover, ureteral stents add some expense to the overall ureteroscopic
procedure and unless a pull string is attached to the distal end of the stent, secondary
cystoscopy is required for stent removal.27
There are clear indications for stenting after the completion of URS. These
include ureteral injury, stricture, solitary kidney, renal insufficiency, or a large residual
stone burden.
Option: Percutaneous antegrade ureteroscopy is an acceptable first-line
treatment in select cases.
Instead of a retrograde endoscopic approach to the ureteral stone, percutaneous
antegrade access can be substituted.28 This treatment option is indicated:
in select cases with large impacted stones in the upper ureter
35
in combination with renal stone removal
in cases of ureteral stones after urinary diversion29
in select cases resulting from failure of retrograde ureteral access to large,

impacted upper ureteral stones.30
Option: Laparoscopic or open surgical stone removal may be considered in

rare cases where SWL, URS, and percutaneous URS fail or are unlikely to be
successful.
The 1997 AUA guideline stated that Open surgery should not be the first-line
treatment.9 The invasiveness and morbidity of open surgery can be avoided. In very
difficult situations, however, such as with very large, impacted stones and/or multiple
ureteral stones, or in cases of concurrent conditions requiring surgery, an alternative
procedure might be desired as primary or salvage therapy. Laparoscopic ureterolithotomy
is a less invasive alternative to open surgery in this setting. Comparative series indicate
that open surgical ureterolithotomy can be replaced by laparoscopic ureterolithotomy in
most situations.31, 32 From the 15 case series of laparoscopic ureterolithotomy included in
the Panels literature review, the median stone-free rate was 88% for the primary
treatment. It is notable that this success was achieved when virtually all of the procedures
were for large and/or impacted calculi.
Recommendations for the Pediatric Patient

Option: Both SWL and URS are effective in this population. Treatment
choices should be based on the childs size and urinary tract anatomy. The
36
small size of the pediatric ureter and urethra favors the less invasive
approach of SWL.
[Based on review of data and Panel consensus/Level III]
Recommendations for the Nonindex Patient

Standard: For septic patients with obstructing stones, urgent decompression
of the collecting system with either percutaneous drainage or ureteral
stenting is indicated. Definitive treatment of the stone should be delayed until
sepsis is resolved.
The compromised delivery of antibiotics into the obstructed kidney mandates that
the collecting system be drained to promote resolution of the infection. The choice of
drainage modality, whether percutaneous nephrostomy or ureteral stent, is left to the
discretion of the urologist, as both have been shown in a randomized trial to be equally
effective in the setting of presumed obstructive pyelonephritis/pyonephrosis.33 Definitive
treatment of the stone should be delayed until sepsis has resolved and the infection is
cleared following a complete course of appropriate antimicrobial therapy.
Discussion
There are two significant changes in treatment approach that distinguish the
present document from the guideline published by the AUA in 1997. The most
significant change is the use of retrograde URS as first-line treatment for middle and
upper ureteral stones with a low probability of spontaneous passage. This change reflects
37
both the vast technological improvements that have been made during the last decade and
the experience and facility that surgeons now have with the procedure. The other change
is the establishment of effective MET to facilitate spontaneous stone passage. These
advances, the current status of other technologies and procedures, issues related to
nonindex patients, and future directions and research germane to this condition will be
subsequently discussed.
Medical Expulsive Therapy

There is growing evidence that MET, the administration of drugs to facilitate
stone passage, can be efficacious. Studies have demonstrated that this approach may
facilitate and accelerate the spontaneous passage of ureteral stones as well as stone
fragments generated with SWL.34-38 Our meta-analysis demonstrated the effectiveness of
MET. Nine percent (CI: -7% to 25%) more patients receiving nifedipine passed their
stones than did controls in our meta-analysis, a difference that was not statistically
significant. In contrast, a statistically significant 29% (CI: 20% to 37%) more patients
passed their stones with alpha blocker therapy than did control patients. These findings
indicate that alpha blockers facilitate ureteral stone passage while nifedipine may provide
a marginal benefit. Therefore, the Panel feels that alpha blockers are the preferred agents
for MET at this time. Similar findings have been reported by Hollingsworth and
associates7, who recently performed a meta-analysis of studies involving alpha blockers
or nifedipine in patients with ureteral stones. The differences in methodology from our
study have been previously mentioned. Patients given either one of these agents had a
greater likelihood of stone passage than those not receiving such therapy. The pooled-risk
ratios and 95% CIs for alpha blockers and calcium channel blockers were 1.54 (1.29 to
38
1.85) and 1.90 (1.51 to 2.40).7 The benefit of adding corticosteroids was reported to be
small.7, 37 Tamsulosin has been the most common alpha blocker utilized in these studies.
However, one small study demonstrated tamsulosin, terazosin, and doxazosin as equally
effective in this setting.39 These studies also demonstrated that MET reduces the stonepassage time and limits pain. The beneficial effects of these drugs are likely attributed to
ureteral smooth muscle relaxation mediated through either inhibition of calcium channel
pumps or alpha-1 receptor blockade. Further prospective and randomized studies are
warranted to determine the patients who best respond to MET. A large, multicenter,
randomized, placebo-controlled study has recently been funded in the United States for
this purpose. Patients with ureteral stones in all segments of the ureter will be randomized
to tamsulosin or placebo.
Shock-wave Lithotripsy
Shock-wave lithotripsy was introduced to clinical practice as a treatment for
ureteral stones in the early 1980s. Today, even with the refinement of endourologic
methods for stone removal such as URS and PNL, SWL remains the primary treatment
for most uncomplicated upper urinary tract calculi. The meta-analysis published by the
AUA Nephrolithiasis Guideline Panel in 1997 documented that the stone-free rate for
SWL for proximal ureteral stones overall was 83% (78 studies, 17,742 patients). To
achieve this result, 1.40 procedures were necessary per patient. The results were very
similar in the distal ureter, with a stone-free rate of 85% (66 studies, 9,422 patients)
necessitating 1.29 primary and secondary procedures per patient. There was no
significant difference between various SWL techniques (SWL with pushback, SWL with
39
stent or catheter bypass, or SWL in situ). Consequently, the Panel suggested that the use
of a ureteral stent to improve stone-free rates was not warranted. This observation is also
confirmed by the present analysis. However, there may be circumstances such as when
the stone is small or of low radiographic density where a stent or ureteral catheter
(sometimes using a contrast agent) may help facilitate localization during SWL. The
Panel considered complications of SWL for ureteral stones to be infrequent.
The current meta-analysis analyzed SWL stone-free results for three locations in
the ureter (proximal, mid, distal). The SWL stone-free results are 82% in the proximal
ureter (41 studies, 6,428 patients), 73% in the mid ureter (31 studies, 1,607 patients), and
74% in the distal ureter (50 studies, 6,981 patients). The results in the 1997 guideline,
which divided the ureter into proximal and distal only, reported SWL stone-free results of
83% and 85%, respectively. The CIs for the distal ureter do not overlap and indicate a
statistically significant worsening of results in the distal ureter from the earlier results. No
change is shown for the proximal ureter. The cause of this difference is not clear.
Additional procedures also were infrequently necessary (0.62 procedures per patient for
proximal ureteral stones, 0.52 for mid-ureteral stones, and 0.37 for distal ureteral stones).
Serious complications were again infrequent. As expected, stone-free rates were lower
and the number of procedures necessary were higher for ureteral stones >10 mm in
diameter managed with SWL.
The outcomes for SWL for ureteral calculi in pediatric patients were similar to
those for adults, making this a useful option, particularly in patients where the size of the
patient (and ureter/urethra) may make URS a less attractive option.
40
The newer generation lithotriptors with higher peak pressures and smaller focal
zones should, in theory, be ideal for the treatment of stones in the ureter but instead have
not been associated with an improvement in stone-free rates or a reduction in the number
of procedures needed when this treatment approach is chosen. In fact, the SWL stone-free
rates for stones in the distal ureter have declined significantly when compared with the
1997 AUA analysis. The explanation for the lack of improvement in SWL outcomes is
unknown.
Although ureteroscopic stone removal is possible with intravenous sedation, one
clear advantage of SWL over URS is that the procedure is more easily and routinely
performed with intravenous sedation or other minimal anesthetic techniques. Therefore,
for the patient who desires treatment with minimal anesthesia, SWL is an attractive
approach.
Shock-wave lithotripsy can be performed with the aid of either fluoroscopy or
ultrasound (US). While some stones in the proximal and distal ureter can be imaged with
US, this imaging modality clearly limits SWL application in the ureter when compared to
fluoroscopy. However, a combination of both fluoroscopy and US can facilitate stone
location and minimize radiation exposure.
As documented in the 1997 AUA report, there appears to be little, if any,
advantage to routine stenting when performing SWL for ureteral stones.
Concerns have been raised, too, regarding the use of SWL to treat distal ureteral
calculi in women of childbearing age because of the theoretical possibility that
unfertilized eggs and/or ovaries may be damaged. To date, no objective evidence has
been discovered to support such concerns, but many centers require that women age 40 or
41
younger be fully informed of the possibility and give their consent before treatment with
SWL.40-44
Ureteroscopy
Ureteroscopy has traditionally constituted the favored approach for the surgical
treatment of mid and distal ureteral stones while SWL has been preferred for the less
accessible proximal ureteral stones. With the development of smaller caliber semirigid
and flexible ureteroscopes and the introduction of improved instrumentation, including
the holmium:YAG laser, URS has evolved into a safer and more efficacious modality for
treatment of stones in all locations in the ureter with increasing experience worldwide.45, 46 Complication rates, most notably ureteral perforation rates, have been reduced
to less than 5%, and long-term complications such as stricture formation occur with an
incidence of 2% or less.47 Overall stone-free rates are remarkably high at 81% to 94%
depending on stone location, with the vast majority of patients rendered stone free in a
single procedure (Figure 1 and Chapter 3).
In 1997, the AUA Nephrolithiasis Clinical Guideline Panel recommended SWL
for <1 cm stones in the proximal ureter and either SWL or URS for >1 cm proximal
ureteral stones.9 With improved efficacy and reduced morbidity currently associated with
ureteroscopic management of proximal ureteral stones, this modality is now deemed
appropriate for stones of any size in the proximal ureter. Indeed, the current analysis
revealed a stone-free rate of 81% for ureteroscopic treatment of proximal ureteral stones,
with surprisingly little difference in stone-free rates according to stone size (93% for
stones <10 mm and 87% for stones >10 mm). The flexible ureteroscope is largely
42
responsible for improved access to the proximal ureter; superior stone-free rates are
achieved using flexible URS (87%) compared with rigid or semirigid URS (77%). These
stone-free rates are comparable to those achieved with SWL.
The middle ureter poses challenges for all surgical stone treatments; the location
over the iliac vessels may hinder access with a semirigid ureteroscope, and identification
and targeting of mid-ureteral stones for SWL has proved problematic due to the
underlying bone. Despite the limitations, ureteroscopic management is still highly
successful; a stone-free rate of 86% was demonstrated in the current analysis, although
success rates declined substantially when treating larger stones (>10 mm) compared with
smaller stones (78% versus 91%, respectively).
Ureteroscopic treatment of distal ureteral stones is uniformly associated with high
success rates and low complication rates. An overall stone-free rate of 94% was achieved
with either a rigid or semirigid ureteroscope, with little drop off in stone-free rates when
treating larger stones. On the other hand, flexible URS was less successful than rigid or
semirigid URS for distal ureteral stones, particularly those >10 mm, likely due to
difficulty maintaining access within the distal ureter with a flexible ureteroscope.
A number of adjunctive measures have contributed to the enhanced success of
ureteroscopic management of ureteral calculi. Historically, stones in the proximal ureter
have been associated with lower success rates than those in the mid and distal ureter, in
part because the proximal ureter is more difficult to access and stone fragments often
become displaced into the kidney where they may be difficult to treat. Improved flexible
ureteroscopes and greater technical skill, along with the introduction of devices to
43
prevent stone migration48, 49 have improved the success of treating proximal ureteral
stones.
Although the efficacy of URS for the treatment of ureteral calculi has been amply
shown, the need for a ureteral stent with its attendant morbidity has biased opinion
towards SWL in some cases. Clearly, SWL is associated with fewer postoperative
symptoms and better patient acceptance than URS. However, a number of recent
prospective, randomized trials have shown that for uncomplicated URS, the ureter may
be left unstented without undue risk of obstruction or colic requiring emergent medical
attention.10, 14-19
Ureteroscopy can also be applied when SWL might be contraindicated or illadvised. Ureteroscopy can be performed safely in select patients in whom cessation of
anticoagulants is considered unsafe.50 In addition, URS has been shown to be effective
regardless of patient body habitus. Several studies have shown that morbidly obese
patients can be treated with success rates and complication rates comparable to the
general population.51, 52 Finally, URS can be used to safely simultaneously treat bilateral
ureteral stones in select cases.53-55
Percutaneous Antegrade Ureteroscopy

Percutaneous antegrade removal of ureteral stones is a consideration in selected
cases, for example, for the treatment of very large (>15 mm diameter) impacted stones in
the proximal ureter between the ureteropelvic junction and the lower border of the fourth
lumbar vertebra.30, 56 In these cases with stone-free rates between 85% and 100%, its
superiority to standard techniques has been evaluated in one prospective randomized57
and in two prospective studies.28, 30 In a total number of 204 patients, the complication
44
rate was low, acceptable, and not specifically different from any other percutaneous
procedure.
Percutaneous antegrade removal of ureteral stones is an alternative when SWL is
not indicated or has failed58 and when the upper urinary tract is not amenable to
retrograde URS; for example, in those with urinary diversion29 or renal transplants.59
Laparoscopic and Open Stone Surgery

Shock-wave lithotripsy, URS, and percutaneous antegrade URS can achieve
success for the vast majority of stone cases. In extreme situations or in cases of
simultaneous open surgery for another purpose, open surgical ureterolithotomy might
rarely be considered.60, 61 For most cases with very large, impacted, and/or multiple
ureteral stones in which SWL and URS have either failed or are unlikely to succeed,
laparoscopic ureterolithotomy is a better alternative than open surgery if expertise in
laparoscopic techniques is available. Both retroperitoneal and transperitoneal
laparoscopic access to all portions of the ureter have been reported. Laparoscopic
ureterolithotomy in the distal ureter is somewhat less successful than in the middle and
proximal ureter, but the size of the stone does not appear to influence outcome.
Although highly effective, laparoscopic ureterolithotomy is not a first-line therapy
in most cases because of its invasiveness, attendant longer recovery time, and the greater
risk of associated complications compared to SWL and URS.
45
Special Considerations
Pregnancy
Renal colic is the most common nonobstetric cause of abdominal pain in pregnant
patients requiring hospitalization. The evaluation of pregnant patients suspected of
having renal colic begins with ultrasonography, as ionizing radiation should be limited in
this setting. If the US examination is unrevealing and the patient remains severely
symptomatic, a limited intravenous pyelogram may be considered. A typical regimen
includes a preliminary plain radiograph (KUB) and two films, 15 minutes and 60 minutes
following contrast administration. Noncontrast computed tomography is uncommonly
performed in this setting because of the higher dose of radiation exposure. Magnetic
resonance imaging can define the level of obstruction, and a stone may be seen as a
filling defect. However, these findings are nonspecific. In addition, there is a paucity of
experience with using this imaging modality during pregnancy.62
Once the diagnosis has been established, these patients have traditionally been
managed with temporizing therapies (ureteral stenting, percutaneous nephrostomy), an
approach often associated with poor patient tolerance. Further, the temporizing approach
typically requires multiple exchanges of stents or nephrostomy tubes during the
remainder of the patient's pregnancy due to the potential for rapid encrustation of these
devices.
A number of groups have now reported successful outcomes with URS in
pregnant patients harboring ureteral stones. The first substantial report was by Ulvik,
et al63 who reported on the performance of URS in 24 pregnant women. Most patients had
stones or edema, and there were no adverse sequelae associated with ureteroscopic stone
46
removal. Similar results have been reported by Lifshitz and Lingeman64 and Watterson et
al65 who found that the ureteroscopic approach was both diagnostic and therapeutic in
pregnant patients with very low morbidity and the need for only short-term ureteral
stenting, if at all, afterwards. When intracorporeal lithotripsy is necessary during
ureteroscopic treatment of calculi in pregnant patients, the holmium laser has the
advantage of minimal tissue penetration, thereby theoretically limiting risk of fetal injury.
Pediatrics
Both SWL and URS are effective treatment alternatives for stone removal in
children. Selection of the most appropriate treatment has to be based on the individual
stone problem, the available equipment and the urologists expertise in treating children.
Children appear to pass stone fragments after SWL more readily than adults.66-71
Ureteroscopy may be used as a primary treatment or as a secondary treatment
after SWL in case of poor stone disintegration. Less efficient SWL disintegration might
be seen in children with stones composed of cystine, brushite and calcium oxalate
monohydrate or when anatomic abnormalities result in difficulties in fluoroscopic or
ultrasonographic visualization of the stone.72-74
One of the main problems with pediatric URS is the size of the ureteroscope
relative to the narrow intramural ureter and the urethral diameter. This problem has lately
been circumvented by the use of smaller ureteroscopes, for example, mini or needle
instruments as well as small flexible semirigid or rigid ureteroscopes and pediatric (6.9
Fr) cystoscopes. With the availability of 4.5 and 6.0 Fr semirigid ureteroscopes, a 5.3 Fr
flexible ureteroscope and a holmium:YAG laser energy source, instrument-related
complications have become uncommon.73-75 However, the utilization of proper technique
47
remains the most important factor for generating successful outcomes in this population.
Percutaneous stone removal is also possible in pediatric patients with comparable
indications to those in adults. Such an approach might be considered for stone removal in
children with a malformation of the lower urinary tract.
Cystine Stones
Individuals with cystinuria are considered nonindex patients by the Panel for a
variety of reasons. There are limited data regarding treatment outcomes in this group.76-83
In vitro studies also show that these stones are commonly resistant to SWL, although the
degree of resistance may be variable.77, 78 The structural characteristics of these stones are
thought to contribute to their decreased SWL fragility. In addition, some of these stones
may be barely opaque on standard imaging or fluoroscopy, potentially compromising
shock-wave focusing. In contrast to SWL, technology currently utilized for intracorporeal
lithotripsy during URS, including the holmium laser, ultrasonic and pneumatic devices,
can readily fragment cystine stones.81
Certain imaging characteristics may predict SWL outcomes for this patient group.
Bhatta and colleagues reported that cystine stones having a rough-appearing external
surface on plain film imaging were more apt to be fragmented with shock-wave energy
than those with a smooth contour.82 Kim and associates reported that the computed
tomography attenuation coefficients of the latter were significantly higher than the roughtype stones.83 Other types of stones with higher attenuation values have also been
demonstrated to be resistant to shock-wave fragmentation.84
Patients with this rare genetic disorder typically have their first stone event early
in life, are prone to recurrent stones, and are consequently subject to repetitive removal
48
procedures. In addition, patients with cystinuria are at risk for developing renal
insufficiency over time.85, 86 Prophylactic medical therapy and close follow-up can limit
recurrence.
Uric acid Stones

Uric acid calculi are typically radiolucent, thus limiting the ability to treat such
patients using in situ SWL. However, this approach may be possible with devices that use
US if the stone can indeed be localized. When properly targeted, these stones fragment
readily with SWL. Uric acid stones have lower computed tomography attenuation values,
and can usually can be distinguished from calcium, cystine, and struvite calculi.87 The
presence of a low attenuation or a radiolucent stone, particularly in a patient with a low
urinary pH, should lead the clinician to suspect this diagnosis. Manipulation of the
urinary pH with oral potassium citrate, sodium citrate, or sodium bicarbonate to a level
ranging from 6.0 to 7.0 may obviate the need for surgical intervention. Moreover, this
medical treatment may allow stone dissolution in patients whose symptoms are
controllable, should prevent the development of future uric acid stones, and has also been
shown to enhance stone clearance with SWL.88 Medical expulsive therapy may be
administered concomitantly. Ureteroscopy is a very effective method of treating patients
who are not candidates for observation.89
Research and Future Directions

Ten years have elapsed since the last publication of the AUA guidelines, and one
year since the EAU recommendations on ureteral stones. Extensive cooperation between
AUA and EAU Panel members has produced this unique collaborative report. This
49
venture should provide the foundation for future collaborative efforts in guideline
development.
The Panel encountered a number of deficits in the literature. While the
management of ureteral stones remains commonly needed, few RCTs were available for
data extraction. The data were inconsistent, starting from the definition of stone sizes and
ending with variable definitions of a stone-free state. These limitations hinder the
development of evidence-based recommendations.
To improve the quality of research, the Panel strongly recommends the following:
conducting RCTs comparing interventional techniques like URS and SWL
conducting pharmacological studies of stone-expulsion therapies as doubleblinded RCTs
reporting stone-free data without inclusion of residual fragments
using consistent nomenclature to report stone size, stone location, stone-free

rates, time point when stone-free rate is determined, or method of imaging to
determine stone-free rate
reporting data stratified by patient/stone characteristics, such as patient age,

stone size, stone location, stone composition, gender, body mass index, and
treatment modality
reporting all associated treatments including placement of ureteral stents or

nephrostomies
using standardized methods to report acute and long-term outcomes
developing methods to predict outcomes for SWL, URS, and MET
50
providing measures of variability such as standard deviation, standard error,

CI, or variance with corresponding average patient numbers
reporting raw data to facilitate meta-analyses
The Panel suggests focusing on the following issues in future investigations:
investigating the proposed current efficacy problems of second and third

generation shock-wave machines and developing approaches to improve SWL
determining the safety of each technique with respect to acute and long-term
effects
investigating the promising medical stone expulsion in basic research studies

and in clinical trials to unravel the underlying mechanisms and to optimize the
treatment regimens
addressing issues such as patient preferences, quality of life, and time until the
patient completed therapy when evaluating treatment strategies. To date, only
a few studies have addressed patient preference.90-92
although largely dependent on different health systems, addressing costeffectiveness
51
Chapter 2: Methodology
Table of Contents
Introduction..................................................................................................................................... 2
Problem Definition.......................................................................................................................... 2
Literature Search and Data Extraction............................................................................................ 3
Evidence Combination.................................................................................................................... 4
Stone-free Analysis..................................................................................................................... 7
Procedures per Patient ................................................................................................................ 8
Complications ............................................................................................................................. 8
Analyses of Data from Adults and Children............................................................................... 9
Guideline Generation and Approvals............................................................................................ 10
Dissemination ............................................................................................................................... 10
Copyright 2007 American Urological Association Education and Research, Inc.

and European Association of Urology
Introduction
This guideline was developed using an explicit approach to address the relevant factors
for choosing among alternative interventions. These factors include outcomes of the
interventions, patient preferences, and the relative priorities of interventions given limited health
care resources. The guideline Panel used scientific evidence to estimate outcomes of treatment
modalities as accurately as possible. Panel members themselves served as proxies for patients in
considering preferences with regard to health and economic outcomes.
The steps taken to develop this guideline are summarized in Chapter 1 and described in
detail in the present Chapter. Steps included problem definition, literature search, data extraction,
systematic evidence combination, guideline generation, approval, and dissemination.
Problem Definition
This guideline was the first joint guideline effort of the American Urological Association
(AUA) and the European Association of Urology (EAU). Initial discussions included
methodology and the scope of the guideline. It was decided that the methodology for problem
definition, data collection, and initial analysis would be similar to that used in the previous AUA
guideline. All treatments commonly performed in the United States and/or Europe were
included in this update except for treatments that were explicitly excluded in the previous
guideline or newer treatments for which insufficient literature exists. The Panel initially desired
to stratify patient data by age (adult versus child), stone size, stone location, and stone
composition. Later, however, the data were found to be insufficient to allow analysis by
composition. The outcomes deemed by the Panel to be of particular interest to the patient
included stone-free rate, number of procedures performed, stone-passage rate or probability of
spontaneous passage, and complications of treatment. The Panel did not examine economic
effects, including treatment costs.
Outcomes were stratified by stone location (proximal, mid, and distal ureter) and by stone
size (dichotomized as 10 mm and >10 mm for surgical interventions, and 5 mm and >5 mm
for medical interventions and observation where possible; exceptions were made when data were
reported, for example as <10 mm and 10 mm). The mid ureter is the part of the ureter that
overlies the bony pelvis, i.e., the position of the ureter that corresponds to the sacroiliac joint; the
proximal ureter is above and the distal ureter is below. Treatments were divided into three broad
groups:
1. Observation and medical therapy
2. Shock-wave lithotripsy and ureteroscopy
3. Open surgery, laparoscopic stone removal, or percutaneous antegrade ureteroscopy.
Literature Search and Data Extraction

The review of the evidence began with a literature search and data extraction. Articles
were selected from a database of papers derived from MEDLINE searches dealing with all forms
of urinary tract stones. This database was maintained by a Panel chair. The abstract of each paper
was independently reviewed by an American and a European Panel member, and articles were
selected for data extraction if any panel member felt it might have useful data. Additional articles
were suggested by Panel members or found as references in review articles. In total, 348
citations entered the extraction process. An American and a European Panel member each
independently extracted data from each article onto a standardized form (Appendix 5). The team
members reconciled the extractions, and the data were entered into a Microsoft Access
(Microsoft, Redmond, WA) database. The Panel scrutinized the entries, reconciled the
inconsistencies in recording, corrected the extraction errors, and excluded some articles from
further analysis for the following reasons:
1. The article was included in the previous guideline.
2. The article did not provide usable data on the outcomes of interest.
3. Results for patients with ureteral stones could not be separated from results for those
with renal stones.
4. The treatments used were not current or were not the focus of the analysis.
5. The article was a review article of data reported elsewhere.
6. The article dealt only with salvage therapy.
A total of 244 of the articles were initially accepted, although some were later rejected
from inclusion in both the efficacy and complications analyses. For example, some articles were
not included in the efficacy analysis but were included in the safety analysis for certain
complications in which there was clarity as far as reported data. A complete list of these articles
is presented in both Appendix 6, ordered by primary author, and Appendix 7, ordered by
reference number. Articles excluded from evidence combination remained candidates as
references to support the discussion in the text of the Guideline.
Evidence Combination
The analytic goal was to generate outcome tables comparing estimates of outcomes
across treatment modalities. To generate an outcome table, estimates of the probabilities and/or
magnitudes of the outcomes are required for each intervention. Ideally, these are derived from a
synthesis or combination of the evidence. Such a combination can be performed in a variety of
ways depending on the nature and quality of the evidence. For example, if there is one wellconducted randomized controlled trial, the results of that trial alone may be used in the outcomes
table while findings of other studies of lesser quality are ignored. Alternatively, if there are no
studies of satisfactory quality for certain outcomes tables or if available studies are not
commensurable, expert opinion may be used to complete the table. Finally, if a number of
studies have some degree of relevance to a particular outcome or outcomes, then meta-analytic
mathematical methods may be used.
A variety of specific meta-analytic methods are available, and selection of a particular
method depends on the nature of the evidence. For this 2007 Guideline for the Management of
Ureteral Calculi, the Panel elected to use the Confidence Profile Method, which provides
methods for analyzing data from studies that are not randomized controlled trials. The Fast*Pro
computer software was used in the analysis. This program provides posterior distributions from
meta-analyses from which the median can be used as a best estimate, and the central 95% of the
distribution serves as a confidence interval. Statistical significance at the p<0.05 level (twotailed) was inferred when zero was not included in the confidence interval.
Because of the paucity of controlled trials found on literature review, however, the
outcome for each intervention was estimated by combining single arms from various clinical
series. These clinical series frequently had very different outcomes, likely due to a combination
of site-to-site variations in patient populations, in the performance of the intervention, in the skill
of those performing the intervention, and different methods of determining stone-free status.
Given these differences, a random-effects, or hierarchical, model was used to combine the
studies.

A random-effects model assumes that there is an underlying true rate for the outcome
being assessed for each site. It further assumes that this underlying rate varies from site to site.
This site-to-site variation in the true rate is assumed to be normally distributed. The method of
meta-analysis used attempts to determine these underlying distributions.
The results of the confidence-profile method are probability distributions that are
described using the median of the distribution with a confidence interval. In this case, the 95%
confidence interval indicates that the probability (Bayesian) of the true value being outside the
interval is 5%. These Bayesian confidence intervals are sometimes called credible intervals.
The Bayseian method of computation assumes a prior distribution that reflects
knowledge about the probability of the outcome before the results of any experiments are known.
The prior distributions selected for this analysis are among a class of noninformative prior
distributions, which means that they correspond to little or no prior knowledge. The existence of
such a prior distribution can cause small changes in results, particularly for small studies. The
prior distribution for all probability parameters is Jeffereys prior (beta distribution with both
parameters set to 0.5). The prior for the variance for the underlying normal distribution is gamma
distributed with both parameters set to 0.5.
Three of the four outcomes identified as important to patients receiving treatment for
ureteral calculi were analyzed using these methods; insufficient data were available to use these
techniques for the outcome procedures per patient. Evidence from the studies meeting the
inclusion criteria and reporting a given outcome was combined within each treatment modality.
Graphs showing the results for each modality were developed to demonstrate similarities and
differences between treatments.

It is important to note that for certain outcomes more data were reported for one or
another treatment modality. While resulting confidence intervals reflect available data, the
probabilities for certain outcomes can vary widely from study to study within one treatment
modality. In addition, the fact that data from only a few randomized controlled trials could be
evaluated may have somewhat biased results. For example, differences in patient selection may
have had more weight in analyses than differing treatment effects. Nevertheless, the results
obtained reflect the best outcome estimates presently available.
Stone-free Analysis
Studies that reported numbers of patients who were stone free after primary procedures
were included in the stone-free analysis. Studies that reported only the combined number of
patients who either were stone free or had clinically insignificant fragments were excluded.
Many studies did not indicate how or when stone-free status was determined.
The stone-free rate was considered at three time points: after the first procedure, after all
consecutive procedures using the primary treatment, and after total treatments. After considering
the data and the way they were reported, the Panel ultimately decided to report only a single
number. That number would be based on the stone-free rate after all consecutive primary
treatments if available for a given group of patients within an article. If not, then the number
would be based on the number of patients stone free after the first primary treatment. If only the
total stone-free rate was available, it would not be used. The Panel elected to use this method
since the ultimate total stone-free rate is expected to be nearly always 100 % in subjects with
ureteral stones. The procedure count data could be used to show how many primary procedures,
on average, would be needed to get the stone-free rate reported.

Procedures per Patient

Unlike the binary outcome of stone-free status (the patient either is or is not stone free),
the number of procedures per patient is a discrete rate. In some cases, discrete rates can be
approximated with a continuous rate, but in order to meta-analyze continuous rates, a measure of
variance (e.g., standard deviation, standard error) is needed in addition to the mean.
Unfortunately, measures of variance were rarely reported in the studies reviewed. As a result,
numbers of procedures per patient were evaluated by calculating the average across studies
weighted by the number of patients in each study.
Procedures per patient were counted in three totals: primary procedures, secondary
procedures, and adjunctive procedures. Primary procedures were all consecutive procedures of
the same type aimed at removing the stone. Secondary procedures were all other procedures
used to remove the stone. Adjunctive procedures were defined as additional procedures that do
not involve active stone removal. One difficulty in estimating the total number of procedures per
patient is that secondary and adjunctive procedures were not reported consistently. Some studies
reported secondary and adjunctive procedures together as the extra procedures performed
beyond the primary procedure. Other studies reported only primary procedures, while others
simply provided an undefined total number of procedures. Since the Panel had decided to
analyze primary, secondary, and adjunctive procedures separately, only studies that specifically
reported data on a type of procedure were included in estimates for that procedure type. This
approach may have overestimated numbers of secondary and adjunctive procedures because
some articles may not have reported that procedures were not performed.
Complications
Initially, the Panel divided complications into three broad categories: acute, long-term,
and medical; however, after examining the available evidence, the Panel determined that this
breakdown was not useful. Complications were variably reported and only studies that
specifically reported data concerning occurrences of complications were included in the analysis.
Transfusions and a composite category of all other acute complications were meta-analyzed.
Several factors caused inaccuracy in the estimates, but did so in opposite directions, thereby
reducing the magnitude of the inaccuracy. For example, including studies that did not
specifically mention that there were no occurrences of a specific complication may have led to
overestimates of complication rates when meta-analyzed. By combining similar complications,
the Panel also potentially mitigated the overestimate by making it more likely that a complication
in the class was reported. The probability that a patient will have a complication may still be
overstated slightly because some patients experience multiple complications. Since the grouping
of complications varies by study, the result of the meta-analysis is best interpreted as the mean
number of complications that a patient may experience rather than as the probability of having a
complication. Moreover, since reporting of complications is not consistent, the estimated rates
given here are probably less accurate than the confidence intervals would indicate. There were
insufficient data to permit meaningful meta-analyses of patient deaths. The estimates of death
rates provided in the guideline are the Panel's expert opinion based on the limited data available.
Analyses of Data from Adults and Children
Data analyses were conducted for two age groups. One analysis included studies of
patients age 18 or younger (or identified as pediatric patients in the article without specifying age
ranges). A separate adult analysis was rejected since many studies included both adults and
children or werent clear about whether children were included. An overall analysis was done
which included all studies including those including children. This overall analysis is primarily
adult patients. The Panel considered the number of children in these cases to be too small to
significantly influence the results.
Guideline Generation and Approvals

After the evidence was combined and outcome tables were produced, the Panel met to
review the results and identify anomalies. Additional teleconferences were held to review
updates to the outcomes tables based on the problems identified. From the evidence in the
outcome tables and expert opinion, the Panel drafted the treatment guideline. The draft was sent
to 81 peer reviewers of whom 26 provided comments; the Panel revised the document based on
the comments received. The guideline was submitted first for approval to the Practice Guidelines
Committee of the AUA and the Guidelines Office of the EAU and then forwarded to the AUA
Board of Directors and the EAU Board for final approval.
Dissemination
The guideline is posted on the American Urological Association website,
www.auanet.org, and on the European Association of Urology website, www.uroweb.org.
Chapter 1 will be published in The Journal of Urology and in European Urology.

10
Chapter 3: Outcomes Analysis for the Management of Ureteral

Calculi
Table of Contents
Introduction........................................................................................................................................2
Observation and Medical Therapies ..................................................................................................3
Shock-wave Lithotripsy and Ureteroscopy........................................................................................5
Efficacy Outcomes .......................................................................................................... 6
Stone-free rates............................................................................................................ 6
Procedure counts ....................................................................................................... 13
Complications and Side Effects .................................................................................... 21
Other Surgical Interventions ............................................................................................................36

Introduction
The underlying purpose of data extraction from the literature by the Panel was to
develop estimates of the outcomes of interest to the patient for each of the relevant
treatments. The data were meta-analyzed to yield estimates of these outcomes. Where
possible and relevant, attempts also were made to determine whether differences among
treatments reached statistical significance. The results of the analysis described in this
chapter provide most of the evidentiary basis for the guideline statements in Chapter 1.
Relevant treatments may vary depending on the patients general condition and
the size, location, and composition of the stone. The Panel initially intended to produce
outcomes tables stratified by each of these variables. However, lack of sufficiently
stratified data constrained the analysis, and outcomes were stratified only by stone
location (proximal, mid, and distal ureter) and by stone size (dichotomized as 10 mm
and >10 mm for surgical interventions and 5 mm and >5 mm for medical interventions
and observation where possible; exceptions were made when data were reported, for
example, as <10 mm and 10 mm). The mid ureter is the part of the ureter that overlies
the bony pelvis, i.e., the position of the ureter that corresponds to the sacroiliac joint; the
proximal ureter is above and the distal ureter is below. Treatments were divided into
three broad groups:
1. Observation and medical therapy primarily for patients with smaller stones
2. Shock-wave lithotripsy (SWL) and ureteroscopy (URS) for patients with
larger stones

3. Open surgery, laparoscopic stone removal, or percutaneous antegrade

ureteroscopy for patients who are not candidates for URS or SWL or who
have failed those treatments
Studies reporting these interventions did not always clearly indicate patient
differences in stone size, location, and composition or segregate patients to treatments
based on those differences. As a result, the findings presented are not based on cleanly
delineated patient groups. Nevertheless, the results represent the Panels best estimates
based on available data.
The Panels attempt to segregate results for pediatric patients from those for
adults was not completely successful as most studies included both adults and children.
Where possible, the Panel performed two analyses, one including all studies regardless of
patient age, and a second including only those studies or groups of patients that were
comprised entirely of pediatric patients. The latter analysis was not possible for
observation/medical therapies due to a lack of data.
Observation and Medical Therapies

Most small stones and many larger stones pass spontaneously. The Panel
attempted to estimate from the literature the probability of spontaneous passage by stone
size, but only limited data were found. For stones 5 mm, meta-analysis of five patient
groups (224 patients) yielded an estimate that 68% would pass spontaneously (95%
confidence interval [CI]: 46% to 85%). For stones >5 mm and 10 mm, analysis of three
groups (104 patients) yielded an estimate that 47% would pass spontaneously (95% CI:
36% to 59%). Details of the meta-analysis are presented in Appendix 8.
Analysis of medical therapies was complicated by the fact that treatments were
not standardized and control groups, where present, may or may not have received
steroids or other therapies. Two medical therapies had sufficient analyzable data:
nifedipine and alpha-1 adrenergic blockers. Analysis of stone-passage rates were done in
three ways. The first combined all single arms evaluating the therapies. Using this
approach, meta-analysis of four studies of nifedipine (160 patients) yielded an estimate of
a 75% passage rate (95% CI: 63% to 84%). Six studies examined alpha blockers (280
patients); the meta-analysis yielded a stone-passage rate of 81% (95% CI: 72% to 88%).
One study compared three alpha blockers (tamsulosin, terazosin, and doxazosin) and
found no differences in passage rates among them (ref 18204).
The second method was a standard Bayesian hierarchical meta-analysis of
available randomized controlled trials (RCTs) that compared either nifedipine or alpha
blockers to control therapy. The results for nifedipine showed an absolute increase of 8%
in stone-passage rates (95% CI: -7% to 25%) which was not statistically significant.
Meta-analysis of alpha blockers versus control showed an absolute increase of 29% in the
stone-passage rate (95% CI: 20% to 37%) which was statistically significant.
The Panel also attempted to determine whether alpha blockers provide superior
stone passage when compared to nifedipine. Two randomized controlled trials were
identified. When hierarchical meta-analysis was performed on these two studies,
tamsulosin provided an absolute increase in stone-passage rate of 14% (95% CI: -4% to
32%) which was not statistically significant. When nonhierarchical methods were used,
the stone-passage improvement increased to 16% (95% CI: 7% to 26%) which was
statistically significant. Finally, the Panel used the results of the meta-analyses versus
controls (second method above) to determine the difference between alpha blockers and
calcium channel blockers. This method allows the use of more data but is risky since it
depends on the control groups having comparable results. The analysis yielded a 20%
improvement in stone-passage rates with alpha blockers, and the 95% CI of 1% to 37%
just reached statistical significance.
Shock-wave Lithotripsy and Ureteroscopy

The majority of data collected were on SWL and URS and thus, the major
analyses focused on these treatments. Because both SWL and URS are conducted using
various techniques, the Panel categorized the data accordingly. For SWL, the Panel used
the categories SWL in situ, SWL-bypass therapy, SWL-pushback, and SWL-other. For
URS, the Panel initially used the categories URS-rigid, URS-semi-rigid, URS-flexible,
URS-combined (groups where some patients received flexible and some rigid), and URSother. As the analysis proceeded, the categories for URS changed. In particular, rigid and
semi-rigid procedures were combined into a single category, labeled URS-rigid, because
the Panel believed these devices were sufficiently similar. Data for those few groups of
patients who all were treated with flexible URS were captured in a category called URSflexible. Since many studies reported groups where flexible URS and rigid URS were
both used and since the Panel concluded that rigid URS is often used when flexible URS
is not, the Panel determined that broader analysis for flexible URS was appropriate. A
category called URS-mixed-flexible included all groups that had some patients receiving
flexible URS or unspecified URS. The URS-flexible groups are included in the URS-

mixed-flexible analysis. In addition to these subgroup analyses, overall analyses of all

SWL groups and of all URS groups were performed.
Data were analyzed for both efficacy and complications. Two efficacy outcomes
were analyzed: stone-free rate and procedure counts. Complications were grouped into
classes. For the complete groupings and complication results, see Appendix 10.
Analyses were performed for the following patient groups where data were
available.
1. Proximal stones 10 mm
2. Proximal stones >10 mm
3. Proximal stones regardless of size
4. Mid-ureteral stones 10 mm
5. Mid-ureteral stones >10 mm
6. Mid-ureteral stones regardless of size
7. Distal stones 10 mm
8. Distal stones >10 mm
9. Distal stones regardless of size
Analyses of pediatric groups were attempted for the same nine groups, although
data were lacking for many groups.
Efficacy Outcomes
Stone-free rates
Stone-free rates were determined initially in several ways. The Panel defined
stone free as completely stone free without residual fragments. If the author used the term
stone free and did not indicate that it could include residual fragments, the panel

assumed that patients were completely stone free. Stone-free data were extracted at three
time points:
1. After the first procedure
2. After all primary procedures (procedures of the same type, i.e., either all SWL or
all URS)
3. After all procedures
The initial analysis was performed separately for each time point. However,
because most studies did not give data for all time points, the panel decided to use one
time point from each study. If the study gave the stone-free rate after all primary
procedures, that number was used. If not, and the study gave the stone-free rate after the
first procedure, then that number was used. The stone-free rate after all procedures was
never used. The intention of the Panel was to provide an estimate of the number of
primary procedures and the stone-free rate after those procedures. Because many studies
only provided stone-free rates after the first procedure, the estimates of stone-free rates
may be a little low. However, since most patients are stone free after the first procedure,
this error should be rather small.
The results of the analysis of stone-free data are presented for the overall group in
Table 1. The Table shows the number of patient groups (G) and total number of patients
(P) that contributed to the analysis. A patient group frequently represents patients from a
single study. However, a study may have contributed multiple groups if the patients were
different in some way and the results were stratified in the article, e.g., if the article
compared two types of rigid scopes, it might provide data for patients treated with each
scope type. This would yield two groups in the group count even though it represented
only one study. It should be noted that there are relatively small numbers of patients and
groups for which mid ureter stone data are available. There are also small numbers of
patients for the categories SWL-bypass, SWL-pushback, and URS-flexible.

Table 1. Stone-Free Rates for Shock-wave Lithotripsy and Ureteroscopy in the Overall Population
Proximal Ureter
All forms
Bypass
In situ
Pushback
Other
Primary/First Treatments
Overall
G/P
Median
CI (2.5 - 97.5)%
41/642
(79 - 85)%
82%
28/476
1/59
12/160
83%
83%
80%
(79 - 87)%
(72 - 91)%
(72 - 86)%
G/P
14/886
1/67
5/578
1/59
7/182
46/224
4/40
18/691
28/155
81%
89%
87%
77%
(77 - 85)%
(75 - 97)%
(82 - 91)%
(71 - 83)%
9/243
1/1
5/134
4/109
Size <10mm
Median
CI (2.5 - 97.5)%
(85 - 93)%
90%
(84 - 97)%
92%
(89 - 98)%
94%
(72 - 91)%
83%
(67 - 91)%
80%
G/P
11/293
1/23
4/186
Size >10mm
Media
CI (2.5 - 97.5)%
(55 - 79)%
68%
(59 - 91)%
78%
(59 - 92)%
78%
6/84
53%
(39 - 67)%
8/230
79%
(71 - 87)%
3/58
5/172
81%
81%
(63 - 93)%
(71 - 88)%
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Mid Ureter
All forms
Bypass
In situ
Pushback
Other
(73 - 85)%
(15 - 100)%
(74 - 89)%
(66 - 85)%
80%
84%
83%
77%
Overall
Size <10mm
Size >10mm
G/P
31/160
1/14
19/115
Median
73%
71%
77%
CI (2.5 - 97.5)%
(66 - 79)%
(45 - 89)%
(69 - 84)%
G/P
5/44
Median
84%
CI (2.5 - 97.5)%
(65 - 95)%
G/P
2/15
Median
76%
CI (2.5 97.5)%
(36 - 97)%
2/14
91%
(67 - 99)%
1/6
96%
(67 - 100)%
11/442
65%
(51 - 77)%
3/30
77%
(47 - 95)%
1/9
66%
(35 - 90)%
30/102
2/14
11/262
19/762
86%
88%
88%
85%
(81 - 89)%
(53 - 99)%
(79 - 94)%
(79 - 89)%
5/80
91%
(81 - 96)%
5/73
78%
(61 - 90)%
1/9
4/71
87%
92%
(59 - 99)%
(82 - 97)%
1/5
4/68
60%
80%
(21 - 91)%
(66 - 90)%
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Distal Ureter
All forms
Bypass
In situ
Pushback
Other
Overall
G/P
Median
CI (2.5 - 97.5)%
50/698
(73 - 75)%*
74%
G/P
17/168
42/649
75%
(73 - 75)%*
14/164
86%
(79 - 92)%
9/965
74%
(56 - 88)%
8/486
71%
(57 - 82)%
3/35
90%
(75 - 98)%
1/1
84%
(15 - 100)%
59/595
1/2
9/431
50/552
94%
10%
93%
94%
(93 - 95)%
(0 - 67)%
(89 - 96)%
(93 - 96)%
13/162
97%
(96 - 98)%
8/412
93%
(88 - 96)%
1/38
12/158
97%
98%
(88 - 100)%
(96 - 99)%
1/10
7/402
79%
94%
(50 - 96)%
(90 - 97)%
Size <10mm
Median
CI (2.5 - 97.5)%
(80 - 91)%
86%
G/P
10/966
Size >10mm
CI (2.5 Median
(57 - 87)%
74%
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Total Ureter
All forms
Bypass
In situ
Pushback
Other
Size <10mm
Size >10mm
G/P
37/562
1/67
24/380
1/59
11/196
Median
86%
92%
85%
83%
88%
CI (2.5 - 97.5)%
(82 - 89)%
(84 - 97)%
(79 - 90)%
(72 - 91)%
(81 - 93)%
G/P
27/2348
1/23
16/1627
Median
67%
78%
65%
CI (2.5 97.5)%
(59 - 75)%
(59 - 91)%
(53 - 76)%
10/698
70%
(57 - 82)%
25/259
1/1
7/206
18/239
93%
84%
87%
95%
(90 - 95)%
(15 - 100)%
(81 - 92)%
(92 - 97)%
19/928
87%
(83 - 90)%
5/94
14/834
81%
88%
(67 - 92)%
(85 - 91)%
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid

Results are presented as medians of the posterior distribution (best central

estimate) with 95% Bayesian CIs (credible intervals [confidence intervals]).
Note that the results of the analysis of URS-all forms are uniformly better than
those for SWL-all forms when all ureteral locations are combined and segregated by size.
The Panel wondered if it could be shown that these results reached statistical significance
for any of the respective ureteral locations. Unfortunately, RCTs comparing these
treatments were generally lacking, making an accurate assessment impossible. However,
the posterior distributions resulting from the meta-analysis can be subtracted, yielding a
posterior for the difference between the treatments. If the CI of this result does not
include 0, then the results may be considered to be statistically significantly different.
This operation is mathematically justifiable but operationally risky: if patients receiving
different treatments are different or if outcome measures are different, results may be
meaningless. Nonetheless, the panel performed the comparison and found that URS
stone-free rates were significantly better than SWL rates for distal ureteral stones 10
mm and >10 mm and for proximal ureteral stones >10 mm. The stone-free result of URS
tended to be better than that of SWL for all mid-ureteral stones, but the difference was
not statistically significant (likely related to small sample size). However, this did not
reach statistical significance which may be related to the small number of patients in
these respective groups. The results with URS using a flexible ureteroscope for proximal
ureteral stones appear better than those achieved with a rigid device, but not at a
statistically significant level.
Stone-free results for pediatric patients are shown in Table 2. The very small
numbers of patients in most groups, particularly for URS, makes comparisons among
10
treatments difficult. However, it does appear that SWL may be more effective in the
pediatric subset than in the overall population, particularly in the mid and distal ureter.

11
Table 2. Stone-Free Rates for Shock-wave Lithotripsy and Ureteroscopy, Pediatric Population
Proximal Ureter
All forms
Bypass
In situ
Pushback
Other
Overall
G/P
Median
CI (2.5 - 97.5)%
7/1
81%
(69 - 90)%
5/43
89%
(72 - 98)%
G/P
3/1
4/6
85%
(65 - 96)%
1/19
99%
(88 - 100)%
3/3
78%
(56 - 93)%
4/24
85%
(59 - 97)%
5/1
57%
(25 - 85)%
1/3
4/1
6%
67%
(0 - 54)%
(38 - 90)%
G/P
Size <10mm
Median
CI (2.5 - 97.5)%
Size >10mm
Median
CI (2.5 - 97.5)%
63%
(21 - 94)%
1/1
98%
(81 - 100)%
2/4
36%
(5 - 81)%
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Overall
Mid Ureter
All forms
Bypass
In situ
Pushback
Other
Size <10mm
Size >10mm
G/P
6/3
Median
82%
CI (2.5 - 97.5)%
(63 - 94)%
G/P
4/16
Median
80%
CI (2.5 - 97.5)%
(41 - 98)%
G/P
1/6
Median
96%
CI (2.5 - 97.5)%
(67 - 100)%
4/3
88%
(70 - 97)%
2/14
91%
(67 - 99)%
1/6
96%
(67 - 100)%
2/3
56%
(8 - 96)%
2/2
50%
(6 - 94)%
3/1
80%
(52 0 96)%
1/5
78%
(37 - 99)%
3/1
80%
(52 - 96)%
1/5
78%
(37 - 99)%
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Distal Ureter
All forms
Bypass
In situ
Pushback
Other
Overall
G/P Median
CI (2.5 - 97.5)%
8/2
80%
(68 - 90)%
G/P
5/13
6/2
77%
(63 - 87)%
3/11
84%
(68 - 94)%
1/2
87%
(71 - 97)%
2/2
95%
(79 - 100)%
2/16
93%
(72 - 100)%
1/1
84%
(15 - 100)%
9/1
92%
(86 - 96)%
2/29
89%
(72 - 98)%
1/7
8/1
84%
93%
(50 - 98)%
(87- 96)%
2/29
89%
(72 - 98)%
Size <10mm
Median
CI (2.5 - 97.5)%
86%
(78 - 92)%
G/P
2/2
Size >10mm
Median
CI (2.5 - 97.5)%
83%
(58 - 97)%
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Total Ureter
All forms
Bypass
In situ
Pushback
Other
Size <10mm
G/P
Median
CI (2.5 - 97.5)%
7/19
87%
(80 - 93)%
G/P
4/6
3/15
86%
(70 - 96)%
1/4
93%
(83 - 98)%
4/47
88%
(72 - 97)%
3/1
55%
(26 - 81)%
3/72
91%
(81 - 97)%
1/5
78%
(37 - 98)%
3/72
91%
(81 - 97)%
1/5
78%
(37 - 98)%
Size >10mm
Median
CI (2.5 - 97.5)%
73%
(52 - 89)%
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid

12
Procedure counts
Procedure counts were captured as three types:
1. Primary procedures the number of times the first removal procedure was
performed.
2. Secondary procedures the number of times an alternative stone removal
procedure(s) was performed.
3. Adjunctive procedures additional procedures performed at a time other than
when the primary or secondary procedures were performed; these could
include procedures related to the primary/secondary procedures such as stent
removals as well as procedures performed to deal with complications; most
adjunctive procedures in the data presented represent stent removals. It is
likely that many stent-related adjunctive procedures were underreported, and
thus the adjunctive procedure count may be underestimated..
While it would have been desirable to calculate a total procedure count, few studies
reported all three types of procedures. Thus, the three types were computed separately.
While adding them together to obtain a total procedure count is possible, the fact that the
data came from different studies reduces the meaning of such a sum. As mentioned in
Chapter 2, it was not possible to perform a meta-analysis due to the lack of variance data,
and only weighted averages could be computed. It was not possible to determine whether
the procedure count results differed by statistically significant amounts due to a lack of
variance data. The procedure count results for the overall population are shown in Tables
3A-D.

13
Table 3A. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Overall
Population, Proximal Ureteral Stones
Stones All Sizes
All forms
Bypass
In situ
Pushback
Other
Primary Treatment
Weighted
G/P
Mean
1.31
37/5902
1.55
1/180
1.28
24/4567
1.10
1/59
11/1096
1.43
G/P
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Stones 10 mm
All forms
Bypass
In situ
Pushback
Other
42/1634
5/124
16/447
26/1187
Primary Treatment
Weighted
G/P
Mean
1.26
16/1243
1.36
1/67
1.28
8/1032
1.10
1/59
6/85
1.04
G/P
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Stones 10 mm
All forms
Bypass
In situ
Pushback
Other
Weighted
Mean
1.02
1.00
1.03
1.02
All forms
Flexible
Mixed flexible
Rigid
Adjunctive Treatment
Weighted
G/P
Mean
0.24
13/1329
1.00
1/180
0.28
6/183
8/416
0.12
12/1715
0.06
6/966
0.09
G/P
G/P
27/1831
Weighted
Mean
0.26
6/197
21/1634
0.04
0.29
Weighted
Mean
0.17
1.00
0.25
0.13
Secondary Treatment
Weighted
G/P
Mean
5/150
0.14
14/1159
4/104
7/451
7/708
Weighted
G/P
Mean
0.77
3/114
1.00
1/67
0.45
2/47
3/112
0.15
2/38
0.11
G/P
5/119
Weighted
Mean
0.64
2/18
3/101
0.28
0.70
9/277
Weighted
Mean
1.02
9/701
Weighted
Mean
0.08
3/36
6/241
1.00
1.02
9/701
0.08
Primary Treatment
Weighted
G/P
Mean
1.49
11/510
2.00
1/23
1.52
4/424
Ureteroscopy
Secondary Treatment
Weighted
G/P
Mean
20/2131
0.07
Secondary Treatment
Weighted
G/P
Mean
5/83
0.21
1/41
0.20
G/P
Weighted
G/P
Mean
0.56
4/45
1.00
1/23
6/63
1.14
4/42
0.21
3/22
0.09
G/P
G/P
Weighted
Mean
6/222
Weighted
Mean
0.12
G/P
5/137
Weighted
Mean
1.07
2/30
3/107
1.00
1.09
1/14
5/208
0.07
0.12
G/P, number of groups/number of patients.

14
Table 3B. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Overall
Population, Mid Ureteral Stones
Mid Ureter All Sizes
All forms
Bypass
In situ
Pushback
Other
Primary Treatment
Weighted
G/P
Mean
10/291
1.11
1/14
1.07
1/13
1.20
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Mid Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
3/71
0.06
Weighted
G/P
Mean
4/241
0.23
1/14
0.14
3/38
0.13
8/264
1.11
6/245
0.21
3/189
0.26
G/P
Weighted
Mean
1.04
1.02
1.11
1.01
G/P
G/P
15/934
Weighted
Mean
0.07
2/66
13/868
0.21
0.06
Weighted
Mean
0.09
1.00
0.26
0.05
25/686
2/53
10/180
15/506
Mid Ureter 10 mm
Secondary Treatment
Weighted
G/P
Mean
9/316
0.18
Primary Treatment
Weighted
G/P
Mean
8/444
1.20
5/416
1.21
3/28
1.00
G/P
7/241
Weighted
Mean
1.02
1/9
6/232
1.00
1.02
Primary Treatment
Weighted
G/P
Mean
4/148
1.52
3/129
1.55
1/19
1.32
G/P
3/18
Weighted
Mean
1.00
1/5
2/13
1.00
1.00
Secondary Treatment
Weighted
G/P
Mean
2/80
0.15
8/357
1/40
3/66
5/291
Weighted
G/P
Mean
2/80
0.15
G/P
7/671
Weighted
Mean
0.06
3/99
Weighted
Mean
0.71
7/671
0.06
3/99
0.71
Secondary Treatment
Weighted
G/P
Mean
G/P
G/P
Weighted
G/P
Mean
G/P
3/119
Weighted
Mean
0.18
1/5
Weighted
Mean
0.20
3/119
0.18
1/5
0.20

15
Table 3C. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Overall
Population, Distal Ureteral Stones
Distal Ureter All Sizes
All forms
Bypass
In situ
Pushback
Other
Primary Treatment
Weighted
G/P
Mean
48/7117
1.22
Secondary Treatment
Weighted
G/P
Mean
30/5069
0.12
Weighted
G/P
Mean
15/3875
0.03
38/5963
1.26
23/4297
0.12
13/3500
0.03
10/1154
1.03
7/772
0.13
2/375
0.02
G/P
Weighted
Mean
1.04
1.00
1.01
1.04
G/P
G/P
25/5124
Weighted
Mean
0.03
24/2848
Weighted
Mean
0.36
25/5124
0.03
24/2848
0.36
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Distal Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
56/5308
1/2
7/277
49/5031
Primary Treatment
Weighted
G/P
Mean
19/2031
1.31
14/1659
1.20
5/372
1.80
G/P
15/1326
Weighted
Mean
1.01
1/38
14/1288
1.00
1.01
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Distal Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Secondary Treatment
Weighted
G/P
Mean
7/250
0.13
Weighted
G/P
Mean
7/250
0.13
G/P
11/1131
Weighted
Mean
0.05
6/397
Weighted
Mean
0.83
11/1131
0.05
6/397
0.83
G/P
Primary Treatment
Weighted
G/P
Mean
13/1065
1.43
Secondary Treatment
Weighted
G/P
Mean
3/1026
0.10
11/1045
1.43
3/1026
0.10
2/20
1.30
G/P
G/P
5/231
Weighted
Mean
1.02
2/148
Weighted
Mean
0.14
1/110
Weighted
Mean
1.00
1/10
4/221
1.00
1.02
2/148
0.14
1/110
1.00
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Weighted
G/P
Mean
G/P

16
Table 3D. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Overall
Population, Total Ureteral Stones
Total Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Primary Treatment
Weighted
G/P
Mean
29/4577
1.33
1/67
1.36
20/3872
1.24
1/59
1.10
7/579
1.95
G/P
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Total Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
17/1474
1/1
3/83
14/1391
Primary Treatment
Weighted
G/P
Mean
21/1860
1.49
1/23
2.00
14/1771
1.50
Weighted
G/P
Mean
6/152
0.61
1/67
1.00
2/47
0.45
8/282
0.13
3/38
0.11
3/38
0.11
G/P
G/P
8/711
Weighted
Mean
0.05
8/711
0.05
Weighted
Mean
0.78
1.00
0.28
0.81
Secondary Treatment
Weighted
G/P
Mean
9/1113
0.11
4/1067
0.10
7/381
1/1
2/18
5/363
Weighted
G/P
Mean
3/45
0.56
1/23
1.00
6/66
1.18
5/46
0.28
2/22
0.09
G/P
G/P
6/234
Weighted
Mean
0.08
G/P
13/494
Weighted
Mean
1.04
3/129
Weighted
Mean
0.89
4/66
9/428
1.02
1.04
1/14
5/220
0.07
0.08
1/14
2/115
0.21
0.97
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Weighted
Mean
1.02
1.00
1.00
1.02
Secondary Treatment
Weighted
G/P
Mean
11/320
0.13
Procedure count results for pediatric patients are shown in Tables 4A-D. Again,
the numbers of patients with available data were small and did not support meaningful
comparisons among treatments.

17
Table 4A. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Pediatric
Population, Proximal Ureteral Stones
Proximal Ureter All Sizes
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Proximal Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Proximal Ureter10 mm
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
Primary Treatment
Weighted
G/P
Mean
5/83
1.28
3/49
1.39
Secondary Treatment
Weighted
G/P
Mean
3/38
0.05
1/13
0.08
Weighted
G/P
Mean
1/5
0.00
2/34
1.12
2/25
0.04
1/5
0.00
G/P
G/P
7/38
Weighted
Mean
0.34
G/P
6/27
Weighted
Mean
1.00
1/9
Weighted
Mean
1.00
1/3
5/24
1.00
1.00
2/6
5/32
0.50
0.31
1/9
1.00
Primary Treatment
Weighted
G/P
Mean
6/69
1.12
Secondary Treatment
Weighted
G/P
Mean
1/3
0.00
Weighted
G/P
Mean
1/3
0.00
1/19
1.42
5/50
1.00
1/3
0.00
1/3
0.00
G/P
G/P
5/156
Weighted
Mean
0.12
G/P
2/55
Weighted
Mean
1.07
3/101
Weighted
Mean
0.70
2/55
1.07
5/156
0.12
3/101
0.70
Primary Treatment
Weighted
G/P
Mean
4/16
1.38
Secondary Treatment
Weighted
G/P
Mean
2/2
0.00
Weighted
G/P
Mean
2/2
0.00
1/12
1.50
3/4
1.00
2/2
0.00
2/2
0.00
G/P
Weighted
Mean
G/P
Weighted
Mean
G/P
Weighted
Mean
All forms
Flexible
Mixed flexible
Rigid

18
Table 4B. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Pediatric
Population, Mid Ureteral Stones
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Mid Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Mid Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Primary Treatment
Weighted
G/P
Mean
4/32
1.44
Secondary Treatment
Weighted
G/P
Mean
1/9
0.11
3/29
1.48
1/9
1/3
G/P
4/18
1.00
Weighted
Mean
1.00
4/18
1.00
G/P
Primary Treatment
Weighted
G/P
Mean
5/42
0.67
2/14
0.02
3/28
2/53
1.00
Weighted
Mean
1.08
2/53
1.08
G/P
Primary Treatment
Weighted
G/P
Mean
1/6
1.33
1/6
0.11
2/12
Weighted
Mean
0.17
2/12
Weighted
Mean
0.75
2/12
0.17
2/12
0.75
Secondary Treatment
Weighted
G/P
Mean
G/P
Weighted
G/P
Mean
4/145
Weighted
Mean
0.09
3/99
Weighted
Mean
0.71
4/145
0.09
3/99
0.71
G/P
Secondary Treatment
Weighted
G/P
Mean
G/P
Weighted
G/P
Mean
1.33
1/5
Weighted
Mean
1.00
1/5
1.00
G/P
Weighted
G/P
Mean
1/5
Weighted
Mean
0.20
1/5
0.20
G/P
1/5
Weighted
Mean
0.20
1/5
0.20
G/P

19
Table 4C. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Pediatric
Population, Distal Ureteral Stones
Primary Treatment
Weighted
G/P
Mean
7/212
1.38
All forms
Bypass
In situ
Pushback
Other
6/188
1.43
4/98
1/24
G/P
10/185
1.00
Weighted
Mean
1.05
2/24
8/161
1.00
1.06
G/P
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Secondary Treatment
Weighted
G/P
Mean
4/98
0.08
Distal Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Distal Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
Primary Treatment
Weighted
G/P
Mean
6/161
1.35
7/190
5/96
1/17
6/173
0.06
0.09
1/17
4/79
0.12
0.85
Secondary Treatment
Weighted
G/P
Mean
1/14
0.36
1/14
3/42
G/P
4/109
1.00
Weighted
Mean
1.03
1/17
3/92
1.00
1.04
3/25
1.44
1/1
1.00
Weighted
Mean
G/P
0.07
Weighted
Mean
0.72
1.48
Primary Treatment
Weighted
G/P
Mean
4/26
1.42
2/43
Weighted
Mean
0.09
3/119
G/P
0.08
Weighted
G/P
Mean
2/43
0.07
G/P
Weighted
G/P
Mean
0.36
8/269
Weighted
Mean
0.10
4/143
Weighted
Mean
0.71
1/17
7/252
0.06
0.10
1/17
3/126
0.12
0.79
Secondary Treatment
Weighted
G/P
Mean
G/P
Weighted
Mean
G/P
Weighted
G/P
Mean
G/P
Weighted
Mean
All forms
Flexible
Mixed flexible
Rigid

20
Table 4D. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Pediatric
Population, Total Ureteral Stones
Total Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Total Ureter 10 mm
All forms
Bypass
In situ
Pushback
Other
Ureteroscopy
All forms
Flexible
Mixed flexible
Rigid
Primary Treatment
Weighted
G/P
Mean
7/196
1.37
Secondary Treatment
Weighted
G/P
Mean
3/17
0.30
Weighted
G/P
Mean
2/3
0.00
3/152
1.48
1/14
0.36
4/44
2/3
3/75
1.00
Weighted
Mean
1.05
5/167
0.00
Weighted
Mean
0.09
3/109
0%
Weighted
Mean
0.58
1/17
2/58
1.00
1.07
1/17
4/150
0.06
0.09
1/17
2/92
0.12
0.67
G/P
Primary Treatment
Weighted
G/P
Mean
3/48
1.39
G/P
Secondary Treatment
Weighted
G/P
Mean
1/2
0.00
1//43
1.44
2/5
G/P
1/5
1.00
Weighted
Mean
1.00
1/5
1.00
G/P
1/2
2/3
G/P
Weighted
G/P
Mean
1/2
0.00
1/2
G/P
1/5
0.00
Weighted
Mean
0.20
1/5
0%
Weighted
Mean
0.20
1/5
0.20
1/5
0.20
Complications and Side Effects

The important complications and side effects are reported grouped into the
following categories:
1. Cardiovascular
2. Death
3. Sepsis
4. Steinstrasse
5. Stricture
6. Transfusion
21
7. Ureteral injury
8. Ureteral obstruction
9. Urinary tract infections (UTI)
10. Overall significant
The last category included data from articles that did not specify the nature of the
complications but simply provided a count of significant complications. This most
frequently occurred when the study indicated that there were no significant
complications. The numbers of specific complications listed in an article were not
summed and counted as overall significant complications. Thus, the estimates for this
category are probably substantially underestimated and are included to show that there
were studies that specified that no complications occurred.
The Panel made no inferences about the nonoccurrence of complications. If an
article did not mention a complication, even if other complications were listed, no
assumption was made that the complication did not occur. This decision may have
caused the presented data to be overestimated because studies where the complication
occurred and was reported were more likely to be included. However, since many studies
did not report complications or may have omitted complications, the complication rates
may be underestimated. It is not known to what extent these competing sources of
inaccuracy counteract each other. For very rare events, such as death, for which the few
recorded instances are probably reported, the estimates given are significant
overestimates.
The complication rate for the overall population by treatment, size, and location
are shown in Table 5. The Panel opted not to compare treatments with regard to
statistically significant differences since articles varied in the complications reported and
22
computing a statistical measure of difference was likely to be misleading. Estimates for

rare events, such as death, are included to indicate that they can occur, but the estimates
are unrealistically high. This situation is likely also true for other serious but rare
complications.

23
Table 5. Complication Occurrence Rates with Shock-Wave Lithotripsy (SWL) and Ureteroscopy (URS) by Treatment, Size, and Location in the Overall
Population
Complication
Category
Stone
Location
Cardiovascular
Distal Ureter
Death
No. of
Groups
No. of
Pts
Med.
Prob.
95% CI
SWL - all types

SWL - in situ
URS - all types
URS - rigid
1
1
1
1
395
395
32
32
2%
2%
4%
4%
(1 - 3)%
(1 - 3)%
(0 - 14)%
(0 - 14)%
Proximal Ureter
SWL - all types

SWL - other
URS - all types
URS - mixed flexible
1
1
1
1
111
111
109
109
0%
0%
2%
2%
(0 - 2)%
(0 - 2)%
(0 - 6)%
(0 - 6)%
Distal Ureter
SWL - all types

SWL - in situ
2
2
1,185
1,185
0%
0%
(0 - 1)%
(0 - 0)%
Size
Treatment
Distal Ureter
10 mm
SWL - all types

SWL - in situ
1
1
341
341
0%
0%
(0 - 1)%
(0 - 1)%
Distal Ureter
10 mm
SWL - all types

SWL - in situ
1
1
105
105
0%
0%
(0 - 2)%
(0 - 2)%
SWL - all types

SWL - in situ
URS - all types
URS - flexible
2
2
1
1
1
238
238
40
40
40
0%
0%
1%
1%
1%
(0 - 1)%
(0 - 1)%
(0 - 6)%
(0 - 6)%
(0 - 6)%
Mid Ureter
Mid Ureter
10 mm
SWL - all types

SWL - in situ
1
1
44
44
1%
1%
(0 - 6)%
(0 - 6)%
Mid Ureter
10 mm
SWL - all types

SWL - in situ
1
1
30
30
1%
1%
(0 - 8)%
(0 - 8)%

24
Population
Complication
Category
Stone
Location
Size
Proximal Ureter
Overall
Significant
No. of
Groups
No. of
Pts
Med.
Prob.
95% CI
SWL - all types

SWL - in situ
URS - all types
URS - flexible
2
2
1
1
1
1,143
1,143
84
84
84
0%
0%
0%
0%
0%
(0 - 0)%
(0 - 0)%
(0 - 3)%
(0 - 3)%
(0 - 3)%
Treatment
Proximal Ureter
10 mm
SWL - all types

SWL - in situ
1
1
151
151
0%
0%
(0 - 2)%
(0 - 2)%
Proximal Ureter
10 mm
SWL - all types

SWL - in situ
1
1
117
117
0%
0%
(0 - 2)%
(0 - 2)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - rigid
11
9
2
18
3
15
2,027
1,974
53
1,902
132
1,770
1%
3%
7%
9%
7%
(0 - 2)%
(0 - 1)%
(0 - 11)%
(5 - 10)%
(4 - 16)%
(4 - 10)%
1%
Distal Ureter
Distal Ureter
10 mm
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - rigid
4
3
1
6
6
809
800
9
532
532
1%
0%
2%
6%
6%
(0 - 2)%
(0 - 1)%
(0 - 24)%
(3 - 12)%
(3 - 12)%
Distal Ureter
10 mm
SWL - all types

SWL - in situ
URS - all types
URS - rigid
2
2
3
3
197
197
177
177
1%
1%
16%
16%
(0 - 3)%
(0 - 3)%
(5 - 35)%
(5 - 35)%

25
Population
Complication
Category
Overall
Significant
Stone
Location
Mid Ureter
Size
Treatment
SWL - all types
SWL - in situ
SWL - other
URS - all types
URS - flexible
URS - rigid
Mid Ureter
10 mm
Mid Ureter
10 mm
Proximal Ureter
Proximal Ureter
10 mm

No. of
Groups
4
2
2
9
1
3
6
No. of
Pts
149
125
24
126
1
27
99
Med.
Prob.
3%
1%
8%
14%
16%
13%
15%
95% CI
(0 - 9)%
(0 - 6)%
(0 - 34)%
(8 - 22)%
(0 - 85)%
(2 - 34)%
(8 - 24)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - rigid
2
1
1
1
1
91
90
1
15
15
1%
0%
16%
14%
14%
(0 - 7)%
(0 - 3)%
(0 - 85)%
(3 - 36)%
(3 - 36)%
URS - all types

URS - rigid
1
1
8
8
14%
14%
(1 - 45)%
(1 - 45)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - flexible
URS - rigid
6
3
3
13
1
5
8
622
453
169
383
8
190
193
4%
1%
11%
11%
3%
12%
10%
(1 - 12)%
(0 - 5)%
(2 - 34)%
(6 - 17)%
(0 - 26)%
(4 - 26)%
(6 - 17)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - rigid
2
1
1
3
2
1
165
151
14
120
98
22
1%
0%
2%
12%
15%
1%
(0 - 7)%
(0 - 2)%
(0 - 16)%
(2 - 32)%
(1 - 47)%
(0 - 11)%
26
Population
Complication
Category
Sepsis
Stone
Location
Size
Treatment
Proximal Ureter
10 mm
Distal Ureter
No. of
Groups
No. of
Pts
Med.
Prob.
95% CI
SWL - all types

SWL - in situ
URS - all types
URS - rigid
1
1
4
2
2
117
117
108
42
66
0%
0%
17%
24%
10%
(0 - 2)%
(0 - 2)%
(6 - 34)%
(2 - 69)%
(3 - 21)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - rigid
6
5
1
7
1
6
2,019
2,003
16
1,954
109
1,845
3%
3%
1%
2%
0%
2%
(2 - 5)%
(2 - 5)%
(0 - 14)%
(1 - 4)%
(0 - 2)%
(1 - 4)%
Distal Ureter
10 mm
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - rigid
2
1
1
1
1
53
44
9
12
12
4%
3%
2%
2%
2%
(1 - 14)%
(0 - 10)%
(0 - 24)%
(0 - 19)%
(0 - 19)%
Distal Ureter
10 mm
SWL - all types

SWL - in situ
1
1
342
342
4%
4%
(2 - 6)%
(2 - 6)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - flexible
2
1
1
4
1
2
398
396
2
199
40
43
5%
2%
10%
4%
1%
5%
(0 - 20)%
(1 - 4)%
(0 - 67)%
(1 - 11)%
(0 - 6)%
(0 - 24)%
Mid Ureter

27
Population
Complication
Category
Sepsis
Steinstrasse
Stone
Location
Size
Treatment
URS - rigid
Mid Ureter
10 mm
Proximal Ureter
No. of
Groups
2
No. of
Pts
156
Med.
Prob.
3%
95% CI
(0 - 14)%
SWL - all types

SWL - other
1
1
1
1
16%
16%
(0 - 85)%
(0 - 85)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - flexible
URS - rigid
5
2
3
8
1
4
4
704
499
205
360
84
213
147
3%
3%
2%
4%
0%
3%
5%
(2 - 4)%
(2 - 5)%
(1 - 6)%
(2 - 6)%
(0 - 3)%
(1 - 7)%
(2 - 10)%
Proximal Ureter
10 mm
SWL - all types

SWL - other
SWL - all types
SWL - in situ
1
1
1
1
14
14
41
41
2%
2%
1%
1%
(0 - 16)%
(0 - 16)%
(0 - 6)%
(0 - 6)%
Proximal Ureter
10 mm
URS - all types

URS - rigid
1
1
41
41
1%
1%
(0 - 6)%
(0 - 6)%
Distal Ureter
SWL - all types

SWL - other
1
1
26
26
4%
4%
(0 - 17)%
(0 - 17)%
Mid Ureter
SWL - all types

SWL - other
1
1
37
37
8%
8%
(2 - 20)%
(2 - 20)%
Proximal Ureter
SWL - all types

SWL - in situ
3
1
235
50
5%
6%
(2 - 10)%
(2 - 15)%

28
Population
Complication
Category
Stone
Location
Stricture
Distal Ureter
Size
Treatment
SWL - other
URS - all types
No. of
Groups
2
1
1
No. of
Pts
185
109
109
Med.
Prob.
4%
0%
0%
95% CI
(1 - 10)%
(0 - 2)%
(0 - 2)%
SWL - all types

SWL - in situ
URS - all types
URS - rigid
2
2
16
2
14
609
609
1,911
76
1,835
0%
0%
1%
4%
1%
(0 - 1)%
(0 - 1)%
(1 - 2)%
(1 - 14)%
(1 - 2)%
Distal Ureter
10 mm
SWL - all types

SWL - in situ
URS - all types
URS - rigid
1
1
2
2
28
28
125
125
1%
1%
2%
2%
(0 - 9)%
(0 - 9)%
(0 - 9)%
(0 - 9)%
Distal Ureter
10 mm
SWL - all types

SWL - in situ
1
1
63
63
0%
0%
(0 - 4)%
(0 - 4)%
SWL - all types

SWL - in situ
URS - all types
URS - flexible
URS - rigid
1
1
7
1
4
3
43
43
326
1
43
283
1%
1%
4%
16%
8%
2%
(0 - 6)%
(0 - 6)%
(2 - 7)%
(0 - 85)%
(2 - 22)%
(1 - 6)%
Mid Ureter
Mid Ureter
10 mm
SWL - all types

SWL - in situ
1
1
15
15
1%
1%
(0 - 15)%
(0 - 15)%
Mid Ureter
10 mm
SWL - all types
24
1%
(0 - 10)%

29
Population
Complication
Category
Stone
Location
Size
Proximal Ureter
Transfusion
No. of
Groups
1
No. of
Pts
24
Med.
Prob.
1%
95% CI
(0 - 10)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - flexible
URS - rigid
2
1
1
8
1
4
4
124
13
111
987
8
164
823
2%
2%
0%
2%
3%
3%
2%
(0 - 8)%
(0 - 17)%
(0 - 2)%
(1 - 5)%
(0 - 26)%
(1 - 8)%
(0 - 5)%
Treatment
SWL - in situ
Proximal Ureter
10 mm
URS - all types

URS - rigid
1
1
64
64
0%
0%
(0 - 4)%
(0 - 4)%
Proximal Ureter
10 mm
URS - all types

URS - rigid
1
1
51
51
0%
0%
(0 - 5)%
(0 - 5)%
SWL - all types

SWL - in situ
URS - all types
1
1
1
1
91
91
109
109
0%
0%
0%
0%
(0 - 3)%
(0 - 3)%
(0 - 2)%
(0 - 2)%
Distal Ureter
Distal Ureter
10 mm
SWL - all types

SWL - in situ
1
1
28
28
1%
1%
(0 - 9)%
(0 - 9)%
Distal Ureter
10 mm
SWL - all types

SWL - in situ
1
1
63
63
0%
0%
(0 - 4)%
(0 - 4)%
SWL - all types

SWL - in situ
1
1
43
43
1%
1%
(0 - 6)%
(0 - 6)%
Mid Ureter
30
Population
Complication
Category
Ureteral Injury
Stone
Location
Size
Treatment
No. of
Groups
No. of
Pts
Med.
Prob.
95% CI
Mid Ureter
10 mm
SWL - all types

SWL - in situ
1
1
15
15
1%
1%
(0 - 15)%
(0 - 15)%
Mid Ureter
10 mm
SWL - all types

SWL - in situ
1
1
28
28
1%
1%
(0 - 9)%
(0 - 9)%
Proximal Ureter
URS - all types

1
1
17
17
1%
1%
(0 - 14)%
(0 - 14)%
Distal Ureter
SWL - All types

SWL - in situ
URS - all types
URS - rigid
1
1
23
4
19
45
45
4,529
298
4,231
1%
1%
3%
5%
3%
(0 - 5)%
(0 - 5)%
(3 - 4)%
(3 - 8)%
(2 - 4)%
Distal Ureter
10 mm
URS - all types

URS - rigid
3
3
215
215
2%
2%
(0 - 5)%
(0 - 5)%
Distal Ureter
10 mm
URS - all types

URS - rigid
1
1
71
71
0%
0%
(0 - 3)%
(0 - 3)%
URS - all types

URS - flexible
URS - rigid
10
1
4
6
514
40
91
423
6%
1%
5%
6%
(3 - 8)%
(0 - 6)%
(1 - 13)%
(3 - 9)%
URS - all types

URS - rigid
2
2
31
31
8%
8%
(0 - 39)%
(0 - 39)%
Mid Ureter
Mid Ureter
10 mm

31
Population
Complication
Category
Stone
Location
Size
Treatment
Mid Ureter
10 mm
Proximal Ureter
Ureteral
Obstruction
No. of
Groups
No. of
Pts
Med.
Prob.
95% CI
URS - all types

URS - rigid
1
1
33
33
1%
1%
(0 - 7)%
(0 - 7)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - flexible
URS - rigid
2
1
1
10
1
3
7
124
13
111
1,005
84
200
805
2%
2%
0%
6%
0%
2%
7%
(0 - 8)%
(0 - 17)%
(0 - 2)%
(3 - 9)%
(0 - 3)%
(0 - 6)%
(4 - 12)%
Proximal Ureter
10 mm
URS - all types

URS - rigid
3
3
74
74
9%
9%
(1 - 28)%
(1 - 28)%
Proximal Ureter
10 mm
URS - all types

URS - rigid
2
2
92
92
1%
1%
(0 - 6)%
(0 - 6)%
SWL - All types

SWL - in situ
SWL - other
URS - all types
URS - rigid
5
4
1
2
2
330
314
16
185
185
3%
2%
1%
2%
2%
(1 - 6)%
(1 - 6)%
(0 - 14)%
(1 - 6)%
(1 - 6)%
Distal Ureter
Distal Ureter
10 mm
SWL - all types

SWL - in situ
SWL - other
4
3
1
95
86
9
5%
4%
2%
(1 - 11)%
(1 - 12)%
(0 - 24)%
Distal Ureter
10 mm
SWL - all types

SWL - in situ
1
1
63
63
0%
0%
(0 - 4)%
(0 - 4)%

32
Population
Complication
Category
Stone
Location
Size
Mid Ureter
No. of
Pts
Med.
Prob.
95% CI
SWL - all types

SWL - in situ
SWL - other
URS - all types
3
2
1
1
1
64
62
2
25
25
9%
6%
10%
1%
1%
(1 - 24)%
(0 - 25)%
(0 - 67)%
(0 - 9)%
(0 - 9)%
Mid Ureter
10 mm
SWL - all types

SWL - in situ
SWL - other
2
1
1
16
15
1
11%
1%
16%
(0 - 46)%
(0 - 15)%
(0 - 85)%
Mid Ureter
10 mm
SWL - all types

SWL - in situ
1
1
28
28
1%
1%
(0 - 9)%
(0 - 9)%
SWL - all types

SWL - bypass
SWL - in situ
SWL - other
4
1
2
1
430
90
320
20
2%
2%
2%
1%
(1 - 4)%
(0 - 7)%
(0 - 6)%
(0 - 12)%
SWL - all types

SWL - other
1
1
14
14
2%
2%
(0 - 16)%
(0 - 16)%
SWL - all types

SWL - in situ
SWL - other
URS - all types
URS - rigid
3
1
2
3
3
87
45
42
458
458
4%
5%
3%
4%
4%
(1 - 12)%
(1 - 14)%
(0 - 13)%
(2 - 7)%
(2 - 7)%
SWL - all types

SWL - other
1
1
9
9
2%
2%
(0 - 24)%
(0 - 24)%
Proximal Ureter
Proximal Ureter
Urinary Tract Infection
No. of
Groups
Treatment
10 mm
Distal Ureter
Distal Ureter
10 mm

33
Population
Complication
Category
Stone
Location
Size
Mid Ureter
Mid Ureter
10 mm
Proximal Ureter
Proximal Ureter
10 mm
Treatment
URS - all types
URS - rigid
No. of
Groups
1
1
No. of
Pts
12
12
Med.
Prob.
2%
2%
95% CI
(0 - 19)%
(0 - 19)%
SWL - all types

SWL - other
URS - all types
URS - rigid
1
1
1
1
37
37
63
63
6%
6%
2%
2%
(1 - 16)%
(1 - 16)%
(0 - 7)%
(0 - 7)%
SWL - all types

SWL - other
1
1
1
1
16%
16%
(0 - 85)%
(0 - 85)%
SWL - all types

SWL - bypass
SWL - in situ
SWL - other
URS - all types
URS - rigid
5
1
1
3
2
1
1
360
90
65
205
224
109
115
4%
1%
8%
4%
4%
4%
3%
(2 - 7)%
(0 - 5)%
(3 - 16)%
(1 - 8)%
(1 - 8)%
(1 - 8)%
(1 - 7)%
SWL - all types

SWL - other
1
1
14
14
2%
2%
(0 - 16)%
(0 - 16)%
No., number; Prob., probability; SWL, shock-wave lithotripsy; URS, ureteroscopy

34
Table 6 summarizes complications for all pediatric groups. Since there are few groups and patients, it was not possible to
stratify data by stone size or location.
Table 6. Complication Occurrence Rates with Shock-Wave Lithotripsy (SWL) and Ureteroscopy (URS) in the Pediatric Population
SWL Overall
SWL in Situ
SWL - Other
G/P
Median
Bleeding
Overall Significant
Complications
2/206
5%
CI
(2.5 - 97.5)%
(0 - 24)%
1/38
1%
(0 - 6)%
Pain
3/106
18%
(9 - 30)%
3/106
18%
Retention
(0 - 7)%
1/63
2%
(0 - 7)%
Sepsis
1/63
2/101
2%
4%
(1 - 12)%
1/63
5%
(1 - 12)%
G/P
Median
2/206
5%
CI
(2.5 - 97.5)%
(0 - 24)%
G/P
Median
CI
(2.5 - 97.5)%
1/38
1%
(0 - 6)%
1/38
1%
(0 - 6)%
(9 - 30)%
Skin
1/168
0%
(0 - 1)%
1/168
0%
(0 - 1)%
Stricture
1/25
1%
(0 - 9)%
1/25
1%
(0 - 9)%
Ureteral Obstruction
4/283
2/63
2%
(1 - 6)%
(1 - 6)%
1/38
1%
(0 - 6)%
(0 - 9)%
3/245
1/25
3%
2%
1%
(0 - 9)%
1/38
1%
(0 - 6)%
URS Overall
URS Mixed Flexible
G/P
Median
Bleeding
1/66
17%
CI
(2.5 - 97.5)%
(9 - 27)%
Infection
Overall Significant
Complications
2/91
6%
5/65
Pain
3/98
1/26
Retention
URS Rigid/Semi-rigid
G/P
Median
CI
(2.5 - 97.5)%
1/66
17%
CI
(2.5 - 97.5)%
(9 - 27)%
(2 - 13)%
1/25
5%
(0 - 17)%
1/66
5%
(1 - 12)%
5%
(1 - 14)%
2/10
11%
(1 - 41)%
3/55
4%
(0 - 13)%
5%
(1 - 13)%
3/98
5%
(1 - 13)%
4%
(0 - 17)%
1/26
4%
(0 - 17)%
3/73
3%
(0 - 9)%
(2 - 11)%
G/P
Median
Sepsis
3/73
3%
(0 - 9)%
Stent Migration
1/25
5%
(0 - 17)%
1/25
5%
(0 - 17)%
Ureteral Injury
6/216
6%
(3 - 10)%
1/29
4%
(0 - 15)%
5/187
6%
1/26
1%
(0 - 9)%
1/26
1%
(0 - 9)%
1/12
2%
(0 - 19)%
1/12
2%
(0 - 19)%
Stricture
5/106
5%
(2 - 11)%
5/106
5%
(2 - 11)%
Other Long -term complications
1/43
12%
(5 - 24)%
1/43
12%
(5 - 24)%
CI, confidence interval

35
Other Surgical Interventions

Open surgery, laparoscopic stone removal, and percutaneous antegrade
ureteroscopy were also considered by the Panel although relatively small numbers of
studies reported on these procedures. Stone-free rate results are shown in Table 7, and
procedure count data are shown in Tables 8A-D. Because these procedures are usually
reserved for special cases, the reported data should not be used to compare procedures
with each other or with SWL or URS. As expected, these more invasive procedures
yielded high stone-free rates.

36
Table 7. Stone-Free Rates for Other Surgical Interventions in the Overall Population
Proximal Ureter
Other Surgeries
Laparoscopic Stone Removal
PNL
Open Surgery
Mid Ureter
Other Surgeries
PNL
Open Surgery
Distal Ureter
Other Surgeries
PNL
Open Surgery
Total Ureter
Other Surgeries
PNL
Open Surgery
Overall
G/P
Median CI (2.5 - 9.5)%
5/91
84%
(75 - 91)%
4/176
95%
(90 - 98)%
G/P
1/1
Size <10mm
Median CI (2.5 - 9.5)%
84%
(15 - 100)%
G/P
Median
G/P
Median
G/P
2/7
Median
76%
Overall
G/P
1/10
Median
98%
CI (2.5 97.5)%
(78 - 100)%
Median
86%
CI (2.5 - 9.5)%
(64 - 97)%
1/122
97%
(92 - 99)%
Median
CI (2.5 - 9.5)%
CI (2.5 - 9.5)%
G/P
Median
G/P
Median
G/P
5/37
2/89
Median
85%
97%
Size >10mm
Size <10mm
Overall
G/P
Size >10mm
Median CI (2.5 - 9.5)%
81%
(54 - 96)%
97%
(92 - 100)%
Size <10mm
Overall
G/P
1/15
G/P
3/13
2/89
CI (2.5 - 9.5)%
Size >10mm
Size <10mm
CI (2.5 - 9.5)%
(38 - 96)%
CI (2.5 - 9.5)%
CI (2.5 - 9.5)%
Size >10mm
CI (2.5 - 9.5)%
(68 - 95)%
(92 - 100)%
G/P, number of groups/number of patients; PNL, percutaneous antegrade ureteroscopy.

37
Table 8A. Procedure Counts for Other Surgical Interventions in the Overall Population,
Proximal Ureteral Stones
Proximal Ureter All Sizes
Other Surgeries
PNL
Open Surgery
Other Surgeries
PNL
Open Surgery
Other Surgeries
PNL
Open Surgery
Primary Treatment
Weighted
G/P
Mean
5/38
1.00
4/176
1.05
Secondary Treatment
Weighted
G/P
Mean
2/61
0.18
3/238
0.04
Weighted
G/P
Mean
1/2
1.00
5/242
0.73
Primary Treatment
Weighted
G/P
Mean
2/7
1.00
Secondary Treatment
Weighted
G/P
Mean
1/6
0.17
Weighted
G/P
Mean
2/7
1.00
Primary Treatment
Weighted
G/P
Mean
4/19
1.00
2/89
1.00
Secondary Treatment
Weighted
G/P
Mean
2/12
0.17
1/66
0.02
Weighted
G/P
Mean
2/7
1.00
3/155
0.58
Table 8B. Procedure Counts for Other Surgical Interventions in the Overall Population, Mid
Ureteral Stones
Other Surgeries
Primary Treatment
Weighted
G/P
Mean
Secondary Treatment
Weighted
G/P
Mean
Weighted
G/P
Mean
Primary Treatment
Weighted
G/P
Mean
1/6
1.00
Secondary Treatment
Weighted
G/P
Mean
1/6
0.17
Weighted
G/P
Mean
1/6
1.00
Primary Treatment
Weighted
G/P
Mean
1/6
1.00
Secondary Treatment
Weighted
G/P
Mean
1/6
0.17
Weighted
G/P
Mean
1/6
1.00

PNL
Open Surgery
Mid Ureter 10 mm
Other Surgeries
PNL
Open Surgery
Mid Ureter 10 mm
Other Surgeries
PNL
Open Surgery

38
Table 8C. Procedure Counts for Other Surgical Interventions in the Overall Population, Distal
Ureteral Stones
Other Surgeries
PNL
Open Surgery
Distal Ureter 10 mm
Other Surgeries
PNL
Open Surgery
Distal Ureter 10 mm
Other Surgeries
PNL
Open Surgery
Primary Treatment
Weighted
G/P
Mean
1/15
1.00
Secondary Treatment
Weighted
G/P
Mean
1/15
0.13
Weighted
G/P
Mean
Primary Treatment
Weighted
G/P
Mean
1/6
1.00
Secondary Treatment
Weighted
G/P
Mean
1/6
0.17
Weighted
G/P
Mean
1/6
1.00
Primary Treatment
Weighted
G/P
Mean
1/6
1.00
Secondary Treatment
Weighted
G/P
Mean
1/6
0.17
Weighted
G/P
Mean
1/61
1.00
1/122
1.00
Table 8D. Procedure Counts for Other Surgical Interventions in the Overall Population, Total
Ureteral Stones
Total Ureter 10 mm
Other Surgeries
PNL
Open Surgery
Total Ureter 10 mm
Other Surgeries
PNL
Open Surgery
Primary Treatment
Weighted
G/P
Mean
2/7
1.00
Secondary Treatment
Weighted
G/P
Mean
1/6
0.17
Weighted
G/P
Mean
2/7
1.00
Primary Treatment
Secondary Treatment
G/P
5/37
1/89
1/18
Weighted
Mean
1.00
1.00
1.00
G/P
2/12
1/66
Weighted
Mean
0.17
0.02
G/P
4/43
3/155
Weighted
Mean
0.30
0.58

39
A single pediatric report provided procedure counts for two patients who had one open procedure
each. Two studies reported stone-free rates for children with open procedures (N=5 patients); the computed
stone-free rate was 82% (95% CI: 43% to 99%).

40
Acknowledgements and Disclaimers

The supporting systematic literature review and data analysis, and the drafting of
this document were conducted by the EAU/AUA Nephrolithiasis Guideline Panel
(hereinafter the Panel). Each association selected a Panel chair who in turn appointed the
Panel members, urologists with specific expertise in this disease.
The mission of the Panel was to develop either analysis- or consensus-based
recommendations, depending on the type of evidence available and Panel processes to
support optimal clinical practices in the management of ureteral calculi. This document
was submitted to 81 urologists and other health care professionals for peer review. After
revision of the document based upon the peer review comments, the guideline was
submitted for approval to the Practice Guidelines Committee of the AUA and the
Guidelines Office of the EAU. Then it was forwarded to the AUA Board of Directors and
the EAU Board for final approval. Funding of the Panel and of the PGC was provided by
the AUA and the EAU, although Panel members received no remuneration for their
work. Each member of the PGC and of the Panel furnished a current conflict of interest
disclosure to the AUA.
The final report is intended to provide medical practitioners with a current
understanding of the principles and strategies for the management of ureteral calculi. The
report is based on an extensive review of available professional literature as well as
clinical experience and expert opinion. Some of the medical therapies currently employed
in the management of ureteral calculi have not been approved by the US Food and Drug
Administration for this specific indication. Thus, doses and dosing regimens may deviate
53
from that employed for the Food and Drug Adminstration-approved indications, and this
difference should be considered in the risk-versus-benefit assessment.
This document provides guidance only, and does not establish a fixed set of rules
or define the legal standard of care. As medical knowledge expands and technology
advances, this guideline will change. Today it represents not absolute mandates but
provisional proposals or recommendations for treatment under the specific conditions
described. For all these reasons, the guideline does not preempt physician judgment in
individual cases. Also, treating physicians must take into account variations in resources,
and in patient tolerances, needs and preferences. Conformance with the guideline
reflected in this document cannot guarantee a successful outcome.
54
2007 Guideline for the Management

of Ureteral Calculi
Appendixes

American Urological Association
Education and Research, Inc.

Table of Contents
Appendix 1: Ureteral Stones Guideline Update Panel Members and Consultants (1997) .............1
Appendix 2: EAU Working Group on Urolithiasis ........................................................................3
Appendix 3: Ureteral Stones Guideline Update Panel Members and Consultants (2007) ............4
Appendix 4: Article Status Report..................................................................................................6
Appendix 5: Article Extraction Form .............................................................................................8
Appendix 6: Bibliography of Extracted Articles Sorted by Primary Author................................13
Appendix 7: Bibliography of Extracted Articles Sorted by ProCite Number ..............................33
Appendix 8: Stone Free Rates for Observation Therapies by Size...............................................50
Appendix 9: Stone Free Rates for Medical Therapies by Size .....................................................51
Appendix 10: Complications Graphs............................................................................................52

Appendix 1: Ureteral Stones Guideline Update Panel

Members and Consultants (1997)
Members:
Joseph W. Segura, M.D., F.A.C.S.
(Chairman)
The Carl Rosen Professor of Urology
Department of Urology
The Mayo Clinic
Rochester, Minnesota
Glenn M. Preminger, M.D., F.A.C.S.
(Panel Facilitator)
Professor, Department of Urology
Duke University Medical Center
Durham, North Carolina
Dean G. Assimos, M.D., F.A.C.S.
Associate Professor of Surgical Sciences
The Bowman Gray School of Medicine
Wake Forest University
Winston-Salem, North Carolina
Stephen P. Dretler, M.D., F.A.C.S.
Clinical Professor of Surgery
Harvard Medical School
Director, Kidney Stone Center
Massachusetts General Hospital
Boston, Massachusetts
Robert K. Kahn, M.D., F.A.C.S.
Chief of Endourology
California Pacific Medical Center
San Francisco, California
James E. Lingeman, M.D., F.A.C.S.
Director of Research
Methodist Hospital Institute for Kidney Stone Disease
Associate Clinical Instructor in Urology
Indiana University School of Medicine
Indianapolis, Indiana

Joseph N. Macaluso, Jr., M.D., F.A.C.S.

Managing Director
The Urologic Institute of New Orleans
Associate Professor of Clinical Urology
Louisiana State University Medical Center School of Medicine
New Orleans, Louisiana
Consultants:
(Consultant in Methodology)
Seattle, Washington
Patrick M. Florer
(Database Design and Coordination)
Dallas, Texas
Curtis Colby
(Editor)
Washington, D.C.

Appendix 2: EAU Working Group on Urolithiasis

Prof. Dr. H-G. Tiselius, Stockholm (S) (chairman)
Prof. Dr. P. Alken, Mannheim (D)
Mr. C. Buck, Glasgow (UK)
Prof. Dr. P. Conort, Paris (F)
Prof. Dr. M. Gallucci, Rome (I)
Dr. Th. Knoll, Mannheim (D)
Prof. Dr. Chr. Trk, Vienna (A)

Appendix 3: Ureteral Stones Guideline Update Panel

Members and Consultants (2007)
Members:
Glenn M. Preminger, M.D., Co-Chair
Division of Urologic Surgery
Duke University Medical Center
Durham, North Carolina
Hans-Gran Tiselius, M.D., Ph.D.,Co-Chair
Department of Urology, Karolinska University Hospital, Huddinge
Division of Urology Karolinska Institutet
Stockholm, Sweden
Dean G. Assimos, M.D., Vice Chair
Wake Forest University School of Medicine
Winston-Salem, North Carolina
Peter Alken, M.D., Ph.D.
Klinikum Mannheim
Medizinische Fakultt Mannheim der Universitt Heidelberg
Mannheim, Germany
Colin Buck, M.D., Ph.D.
Brownlee House
Carluke, Scotland
United Kingdom
Michele Gallucci, M.D., Ph.D.
Urologia
Istituto Regina Elena
Rome, Italy
Thomas Knoll, M.D., Ph.D.
Klinikum Mannheim
Medizinische Fakultt Mannheim der Universitt Heidelberg
Mannheim, Germany

James E. Lingeman, M.D.

Methodist Hospital Institute for Kidney Stone Disease
Indiana University School of Medicine
Indianapolis, Indiana
Stephen Y. Nakada, M.D.
Division of Urology
Department of Surgery
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Margaret Sue Pearle, M.D., Ph.D.
University of Texas Southwestern Medical Center
Dallas, Texas
Kemal Sarica, M.D., Ph.D.
Memorial Hospital
Istanbul, Turkey
Christian Trk, M.D., Ph.D.
Urology Department
Rudolfspital
Vienna, Austria
J. Stuart Wolf, Jr., M.D.
University of Michigan
Ann Arbor, MI
Consultants:
Patrick M. Florer
Diann Glickman, PharmD

Appendix 4: Article Status Report


Appendix 5: Article Extraction Form

(continued on next page)



10

11

12
Appendix 6: Bibliography of Extracted Articles Sorted

by Primary Author
(includes Procite number and citation)
15572
Abdel-Khalek, M., Sheir, K., Elsobky, E., Showkey, S., Kenawy, M. Prognostic factors for
extracorporeal shock-wave lithotripsy of ureteric stones--A multivariate analysis study.
Scandinavian Journal of Urology & Nephrology. 2003; 37: 413-8
15606
Aghamir, S. K., Mohseni, M. G., Ardestani, A. Treatment of ureteral calculi with ballistic lithotripsy.
Journal of Endourology. 2003; 17: 887-90
17128
Akhtar, M. S., Akhtar, F. K. Utility of the Lithoclast in the treatment of upper, middle and lower
ureteric calculi. Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland. 2003;
1: 144-8
19854
Akhtar, S., Ather, M. H. Appropriate cutoff for treatment of distal ureteral stones by single session in
situ extracorporeal shock wave lithotripsy. Urology. 2005; 66: 1165-8
7686
al Busaidy, S.S., Prem, A.R., Medhat, M. Paediatric ureteroscopy for ureteric calculi: a 4-year
experience British Journal of Urology. 1997; 80: 797-801
8030
al Busaidy, S.S., Prem, A.R., Medhat, M., Giriraj, D., Gopakumar, P., Bhat, H.S. Paediatric ureteric
calculi: efficacy of primary in situ extracorporeal shock wave lithotripsy British Journal of Urology.
1998; 82: 90-96
18958
Albala, D. M., Siddiqui, K. M., Fulmer, B., Alioto, J., Frankel, J., Monga, M. Extracorporeal shock
wave lithotripsy with a transportable electrohydraulic lithotripter: experience with >300 patients.
BJU International. 2005; 96: 603-7
16046
Al-Busaidy, S. S., Prem, A. R., Medhat, M., Al-Bulushi, Y. H. Ureteric calculi in children: Preliminary
experience with holmium:yag laser lithotripsy. BJU International. 2004; 93: 1318-23
6472
Al-Rasheed, S.A., el-Faqih, S.R., Husain, I., Abdurrahman, M., al-Mugeirin, M.M. The aetiological
and clinical pattern of childhood urolithiasis in Saudi Arabia International Urology & Nephrology.
1995; 27: 349-355
16616
Anagnostou, T., Tolley, D. Management of ureteric stones. [Review] [64 refs] European Urology.
2004; 45: 714-21
10696
Andreoni, C., Afane, J., Olweny, E., Clayman, R. V. Flexible ureteroscopic lithotripsy: first-line
therapy for proximal ureteral and renal calculi in the morbidly obese and superobese patient
15872
Ansari, M. S., Gupta, N. P., Seth, A., Hemal, A. K., Dogra, P. N., Singh, T. P. Stone fragility: its
therapeutic implications in shock wave lithotripsy of upper urinary tract stones. International
Urology & Nephrology. 2003; 35: 387-92
18154
Aridogan, I. A., Zeren, S., Bayazit, Y., Soyupak, B., Doran, S. Complications of pneumatic
ureterolithotripsy in the early postoperative period. Journal of Endourology. 2005; 19: 50-3
14430
Arrabal-Martin, M., Pareja-Vilches, M., Gutierrez-Tejero, F., Mijan-Ortiz, J. L., Palao-Yago, F.,
Zuluaga-Gomez, A. Therapeutic options in lithiasis of the lumbar ureter. European Urology. 2003;
43: 556-63
9598
Ather, M.H., Memon, A. Therapeutic efficacy of Dornier MPL 9000 for prevesical calculi as judged
by efficiency quotient Journal of Endourology. 2000; 14: 551-553

13
10157
Ather, M.H., Paryani, J., Memon, A., Sulaiman, M.N. A 10-year experience of managing ureteric
calculi: changing trends towards endourological intervention--is there a role for open surgery? BJU
International. 2001; 88: 173-177
15852
Auge, B. K., Pietrow, P. K., Lallas, C. D., Raj, G. V., Santa-Cruz, R. W., Preminger, G. M. Ureteral
access sheath provides protection against elevated renal pressures during routine flexible
ureteroscopic stone manipulation. Journal of Endourology. 2004; 18: 33-6
12508
Aynehchi, S., Samadi, A. A., Gallo, S. J., Konno, S., Tazaki, H., Eshghi, M. Salvage extracorporeal
shockwave lithotripsy after failed distal ureteroscopy. Journal of Endourology. 2002; 16: 355-8
12452
Azm, T. A., Higazy, H. Effect of diuresis on extracorporeal shockwave lithotripsy treatment of

ureteric calculi. Scandinavian Journal of Urology & Nephrology. 2002; 36: 209-12
11760
Bassiri, A., Ahmadnia, H., Darabi, M. R., Yonessi, M. Transureteral lithotripsy in pediatric practice.
8454
Beaghler, M., Poon, M., Ruckle, H., Stewart, S., Weil, D. Complications employing the
holmium:YAG laser Journal of Endourology. 1998; 12: 533-535
15976
Beiko, D. T., Beasley, K. A., Koka, P. K., Watterson, J. D., Nott, L., Denstedt, J. D., Razvi, H. Upper
tract imaging after ureteroscopic holmium:yag laser lithotripsy: when is it necessary?. Canadian
Journal of Urology. 2003; 10: 2062-7
8793
Bendhack, M.L., Grimm, M.O., Ackermann, R., Vogeli, T. Primary treatment of ureteral stones by
new multiline lithotripter Journal of Endourology. 1999; 13: 339-342
7665
Bichler, K.H., Lahme, S., Strohmaier, W.L. Indications for open stone removal of urinary calculi
Urologia Internationalis. 1997; 59: 102-108
7781
Bierkens, A.F., Hendrikx, A.J., De La Rosette, J.J., Stultiens, G.N., Beerlage, H.P., Arends, A.J.,
Debruyne, F.M. Treatment of mid- and lower ureteric calculi: extracorporeal shock-wave lithotripsy
vs laser ureteroscopy. A comparison of costs, morbidity and effectiveness British Journal of
Urology. 1998; 81: 31-35
8559
Biri, H., Kupeli, B., Isen, K., Sinik, Z., Karaoglan, U., Bozkirli, I. Treatment of lower ureteral stones:
extracorporeal shockwave lithotripsy or intracorporeal lithotripsy? Journal of Endourology. 1999;
13: 77-81
10382
Borboroglu, P. G., Amling, C. L., Schenkman, N. S., Monga, M., Ward, J. F., Piper, N. Y., Bishoff, J.
T., Kane, C. J. Ureteral stenting after ureteroscopy for distal ureteral calculi: a multi-institutional
prospective randomized controlled study assessing pain, outcomes and complications Journal of
Urology. 2001; 166: 1651-7
10302
Brinkmann, O. A., Griehl, A., Kuwertz-Broking, E., Bulla, M., Hertle, L. Extracorporeal shock wave
lithotripsy in children. Efficacy, complications and long-term follow-up. European Urology. 2001;
39: 591-7
11778
Buchholz, N. P., Rhabar, M. H., Talati, J. Is measurement of stone surface area necessary for SWL
treatment of nonstaghorn calculi?. Journal of Endourology. 2002; 16: 215-20
10304
Buchholz, N. P., Van Rossum, M. The radiolucent ureteric calculus at the end of a contrast-medium
column: where to focus the shock waves Bju International. 2001; 88: 325-8
9994
Buchholz, N.P., van Rossum, M. Shock wave lithotripsy treatment of radiolucent ureteric calculi
with the help of contrast medium European Urology. 2001; 39: 200-203
11254
Bugg, C. E. Jr., El-Galley, R., Kenney, P. J., Burns, J. R. Follow-up functional radiographic studies
are not mandatory for all patients after ureteroscopy. Urology. 2002; 59: 662-7
15756
Bultitude, M. F., Tiptaft, R. C., Dasgupta, P., Glass, J. M. Treatment of urolithiasis in the morbidly
obese. Obesity Surgery. 2004; 14: 300-4

14
17092
Butler, M. R., Power, R. E., Thornhill, J. A., Ahmad, I., McLornan, I., McDermott, T., Grainger, R.
An audit of 2273 ureteroscopies--A focus on intra-operative complications to justify proactive
management of ureteric calculi. Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh &
Ireland. 2004; 2: 42-6
12032
Byrne, R. R., Auge, B. K., Kourambas, J., Munver, R., Delvecchio, F., Preminger, G. M. Routine
ureteral stenting is not necessary after ureteroscopy and ureteropyeloscopy: a randomized trial.
6656
Carringer, M., Swartz, R., Johansson, J.E. Management of ureteric calculi during pregnancy by
ureteroscopy and laser lithotripsy British Journal of Urology. 1996; 77: 17-20
7184
Cass, A.S. Comparison of first-generation (Dornier HM3) and second-generation (Medstone STS)
lithotripters: treatment results with 145 renal and ureteral calculi in children Journal of Endourology.
1996; 10: 493-499
14548
Cervenakov, I., Fillo, J., Mardiak, J., Kopecny, M., Smirala, J., Lepies, P. Speedy elimination of
ureterolithiasis in lower part of ureters with the alpha 1-blocker--tamsulosin. International Urology &
Nephrology. 2002; 34: 25-9
11472
Chandhoke, P. S., Barqawi, A. Z., Wernecke, C., Chee-Awai, R. A. A randomized outcomes trial of
ureteral stents for extracorporeal shock wave lithotripsy of solitary kidney or proximal ureteral
stones. Journal of Urology. 2002; 167: 1981-3
10892
Chang, C. P., Huang, S. H., Tai, H. L., Wang, B. F., Yen, M. Y., Huang, K. H., Jiang, H. J., Lin, J.
Optimal treatment for distal ureteral calculi: extracorporeal shockwave lithotripsy versus
ureteroscopy Journal of Endourology. 2001; 15: 563-6
15778
char, E., Achar, R. A., Paiva, T. B., Campos, A. H., Schor, N. Amitriptyline eliminates calculi
through urinary tract smooth muscle relaxation. Kidney International. 2003; 64: 1356-64
11474
Chen, Y. T., Chen, J., Wong, W. Y., Yang, S. S., Hsieh, C. H., Wang, C. C. Is ureteral stenting
necessary after uncomplicated ureteroscopic lithotripsy? A prospective, randomized controlled trial.
[See comments.]. Journal of Urology. 2002; 167: 1977-80
10528
Cheung, M. C., Lee, F., Leung, Y. L., Wong, B. B., Chu, S. M., Tam, P. C. Outpatient ureteroscopy:
predictive factors for postoperative events Urology. 2001; 58: 914-8
13596
Cheung, M. C., Lee, F., Leung, Y. L., Wong, B. B., Tam, P. C. A prospective randomized controlled
trial on ureteral stenting after ureteroscopic holmium laser lithotripsy. Journal of Urology. 2003;
169: 1257-60
10271
Cheung, M.C., Lee, F., Yip, S.K., Tam, P.C. Outpatient holmium laser lithotripsy using semirigid
ureteroscope. Is the treatment outcome affected by stone load? European Urology. 2001; 39: 702708
9602
Cheung, M.C., Yip, S.K., Lee, F.C., Tam, P.C. Outpatient ureteroscopic lithotripsy: selective
internal stenting and factors enhancing success Journal of Endourology. 2000; 14: 559-564
14076
Chow, G. K., Patterson, D. E., Blute, M. L., Segura, J. W. Ureteroscopy: Effect of technology and
technique on clinical practice. Journal of Urology. 2003; 170: 99-102
15616
Cimentepe, E., Unsal, A., Saglam, R., Balbay, M. D. Comparison of clinical outcome of
extracorporeal shockwave lithotripsy in patients with radiopaque v radiolucent ureteral calculi.
10828
Coll, D. M., Varanelli, M. J., Smith, R. C. Relationship of spontaneous passage of ureteral calculi to
stone size and location as revealed by unenhanced helical CT AJR. American Journal of
Roentgenology. 2002; 178: 101-3

15
15798
Collins, J. W., Keeley, F. X., Jr, Timoney, A. Cost analysis of flexible ureterorenoscopy. BJU
6947
Colombo, T., Zigeuner, R., Altziebler, S., Pummer, K., Stettner, H., Hubmer, G. Effect of
extracorporeal shock wave lithotripsy on prostate specific antigen Journal of Urology. 1996; 156:
1682-1684
9663
Cooper, J.T., Stack, G.M., Cooper, T.P. Intensive medical management of ureteral calculi Urology.
2000; 56: 575-578
9391
Coz, F., Orvieto, M., Bustos, M., Lyng, R., Stein, C., Hinrichs, A., San Francisco, I. Extracorporeal
shockwave lithotripsy of 2000 urinary calculi with the modulith SL-20: success and failure according
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Shiroyanagi, Y., Yagisawa, T., Nanri, M., Kobayashi, C., Toma, H. Factors associated with failure
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Shokeir, A.A., Mutabagani, H. Rigid ureteroscopy in pregnant women British Journal of Urology.
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7162
Shroff, S., Watson, G.M., Parikh, A., Thomas, R., Soonawalla, P.F., Pope, A. The holmium: YAG
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Silver, R.I. A fishnet gantry for pediatric extracorporeal shock wave lithotripsy on the Sonolith 3000
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Singal, R.K., Denstedt, J.D. Contemporary management of ureteral stones. Urologic Clinics of
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Singal, R.K., Razvi, H.A., Denstedt, J.D. Secondary ureteroscopy: results and management
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Singh, I., Gupta, N.P., Hemal, A.K., Dogra, P.N., Ansari, M.S., Seth, A., Aron, M. Impact of power
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Sinha, M., Kekre, N. S., Chacko, K. N., Devasia, A., Lionel, G., Pandey, A. P., Gopalakrishnan, G.
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Sinha, R., Sharma, N. Retroperitoneal laparoscopic management of urolithiasis Journal of

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Skrepetis, K., Doumas, K., Siafakas, I., Lykourinas, M. Laparoscopic versus open ureterolithotomy.
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Slavkovic, A., Radovanovic, M., Siric, Z., Vlajkovic, M., Stefanovic, V. Extracorporeal shock wave
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Smith, D.P., Jerkins, G.R., Noe, H.N. Urethroscopy in small neonates with posterior urethral valves
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18576
Soares, R. S., Romanelli, P., Sandoval, M. A., Salim, M. M., Tavora, J. E., Abelha, D. L., Jr.
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Sofer, M., Watterson, J. D., Wollin, T. A., Nott, L., Razvi, H., Denstedt, J. D. Holmium:YAG laser
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29
16010
Sozen, S., Kupeli, B., Tunc, L., Senocak, C., Alkibay, T., Karaoglan, U., Bozkirli, I. Management of
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15612
Srivastava, A., Gupta, R., Kumar, A., Kapoor, R., Mandhani, A. Routine stenting after ureteroscopy
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9123
Strohmaier, W.L., Schubert, G., Rosenkranz, T., Weigl, A. Comparison of extracorporeal shock
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Urology. 1999; 36: 376-379
10968
Sun, Y., Wang, L., Liao, G., Xu, C., Gao, X., Yang, Q., Qian, S. Pneumatic lithotripsy versus laser
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9057
Taari, K., Lehtoranta, K., Rannikko, S. Holmium:YAG laser for urinary stones Scandinavian Journal
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18914
Tan, A. H., Al-Omar, M., Denstedt, J. D., Razvi, H. Ureteroscopy for pediatric urolithiasis: An
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Tan, A. H., Al-Omar, M., Watterson, J. D., Nott, L., Denstedt, J. D., Razvi, H. Results of shockwave
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8164
Tan, P.K., Tan, S.M., Consigliere, D. Ureteroscopic lithoclast lithotripsy: a cost-effective option
13262
Tan, Y. M., Yip, S. K., Chong, T. W., Wong, M. Y., Cheng, C., Foo, K. T. Clinical experience and
results of ESWL treatment for 3,093 urinary calculi with the Storz Modulith SL20 lithotripter at the
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15788
Tansu, N., Obek, C., Onal, B., Yalcin, V., Oner, A., Solok, V. A simple position to provide better
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lithotripsy using the Siemens Lithostar. European Urology. 2004; 45: 352-5
8307
Tawfiek, E.R., Bagley, D.H. Management of upper urinary tract calculi with ureteroscopic
techniques Urology. 1999; 53: 25-31
7488
Tawfiek, E.R., Grasso, M., Bagley, D.H. Initial use of Browne Pneumatic Impactor Journal of
Endourology. 1997; 11: 121-124
11038
Taylor, A. L., Oakley, N., Das, S., Parys, B. T. Day-case ureteroscopy: an observational study. Bju
8013
Teh, C.L., Zhong, P., Preminger, G.M. Laboratory and clinical assessment of pneumatically driven
intracorporeal lithotripsy Journal of Endourology. 1998; 12: 163-169
7599
Teichman, J.M., Rao, R.D., Rogenes, V.J., Harris, J.M. Ureteroscopic management of ureteral
calculi: electrohydraulic versus holmium:YAG lithotripsy Journal of Urology. 1997; 158: 1357-1361
6981
Terai, A., Takeuchi, H., Terachi, T., Kawakita, M., Okada, Y., Yoshida, H., Isokawa, Y., Taki, Y.,
Yoshida, O. Intracorporeal lithotripsy with the Swiss Lithoclast International Journal of Urology.
1996; 3: 184-186
18972
Thomas, J. C., DeMarco, R. T., Donohoe, J. M., Adams, M. C., Brock, J. W., 3rd, Pope, J. C, 4th
Pediatric ureteroscopic stone management. Journal of Urology. 2005; 174: 1072-4
6490
Thuroff, S., Chaussy, C.G. First clinical experience and in situ treatment of ureteric stones using
Lithostar Multiline lithotripter Journal of Endourology. 1995; 9: 367-370

30
19044
Tiselius, H. G. Removal of ureteral stones with extracorporeal shock wave lithotripsy and
ureteroscopic procedures. What can we learn from the literature in terms of results and treatment
efforts?. Urological Research. 2005; 33: 185-90
10522
Tiselius, H. G., Ackermann, D., Alken, P., Buck, C., Conort, P., Gallucci, M., Working Party on
Lithiasis, European Association of Urology Guidelines on urolithiasis. European Urology. 2001; 40:
362-71
14432
Tligui, M., El Khadime, M. R., Tchala, K., Haab, F., Traxer, O., Gattegno, B., Thibault, P.
Emergency extracorporeal shock wave lithotripsy (ESWL) for obstructing ureteral stones. European
Urology. 2003; 43: 552-5
19036
Tombal, B., Mawlawi, H., Feyaerts, A., Wese, F. X., Opsomer, R., Van Cangh, P. J. Prospective
randomized evaluation of emergency extracorporeal shock wave lithotripsy (eswl) on the short-time
outcome of symptomatic ureteral stones. European Urology. 2005; 47: 855-9
10256
Toth, C.S., Varga, A., Flasko, T., Tallai, B., Salah, M.A., Kocsis, I. Percutaneous ureterolithotomy:
direct method for removal of impacted ureteral stones Journal of Endourology. 2001; 15: 285-290
15058
Troy, A., Jones, G., Moussa, S. A., Smith, G., Tolley, D. A. Treatment of lower ureteral stones
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7909
Turk, I., Deger, S., Roigas, J., Fahlenkamp, D., Schonberger, B., Loening, S.A. Laparoscopic
ureterolithotomy Techniques in Urology. 1998; 4: 29-34
8376
Turk, T.M., Jenkins, A.D. A comparison of ureteroscopy to in situ extracorporeal shock wave
lithotripsy for the treatment of distal ureteral calculi Journal of Urology. 1999; 161: 45-47
18376
Unsal, A., Cimentepe, E., Balbay, M. D. Routine ureteral dilatation is not necessary for
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9526
Van Savage, J.G., Palanca, L.G., ersen, R.D., Rao, G.S., Slaughenhoupt, B.L. Treatment of distal
ureteral stones in children: similarities to the american urological association guidelines in adults
16028
Varkarakis, J., Protogerou, V., Albanis, S., Sofras, F., Deliveliotis, C. Comparison of success rates
and financial cost of extracorporeal shock-wave lithotripsy in situ and after manipulation for
proximal ureteral stones. Urological Research. 2003; 31: 286-90
9127
Virgili, G., Mearini, E., Micali, S., Miano, R., Vespasiani, G., Porena, M. Extracorporeal piezoelectric
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12094
Volkmer, B. G., Nesslauer, T., Kuefer, R., Loeffler, M., Kraemer, S. C., Gottfried, H. W. Evaluation
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8106
Vorreuther, R., Klotz, T., Heidenreich, A., Nayal, W., Engelmann, U. Pneumatic v electrokinetic
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17432
Wang, L. J., Ng, C. J., Chen, J. C., Chiu, T. F., Wong, Y. C. Diagnosis of acute flank pain caused
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12758
Watterson, J. D., Girvan, A. R., Beiko, D. T., Nott, L., Wollin, T. A., Razvi, H., Denstedt, J. D.
Ureteroscopy and holmium:yag laser lithotripsy: an emerging definitive management strategy for
symptomatic ureteral calculi in pregnancy. Urology. 2002; 60: 383-7
11960
Weizer, A. Z., Auge, B. K., Silverstein, A. D., Delvecchio, F. C., Brizuela, R. M., Dahm, P., Pietrow,
P. K., Lewis, B. R., Albala, D. M., Preminger, G. M. Routine postoperative imaging is important
after ureteroscopic stone manipulation. Journal of Urology. 2002; 168: 46-50

31
7170
Wolf, J.S., Jr., Bub, W.L., Endicott, R.C., Clayman, R.V. Use of intravenous contrast material during
in situ extracorporeal shock wave lithotripsy of ureteral calculi Journal of Urology. 1997; 157: 38-41
9013
Wollin, T.A., Teichman, J.M., Rogenes, V.J., Razvi, H.A., Denstedt, J.D., Grasso, M. Holmium:YAG
lithotripsy in children Journal of Urology. 1999; 162: 1717-1720
8310
Wong, M.Y. Evolving technique of percutaneous nephrolithotomy in a developing country:

Singapore General Hospital experience Journal of Endourology. 1998; 12: 397-401
20034
Wu, C. F., Chen, C. S., Lin, W. Y., Shee, J. J., Lin, C. L., Chen, Y., Huang, W. S. Therapeutic
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17104
Wu, C. F., Shee, J. J., Lin, W. Y., Lin, C. L., Chen, C. S. Comparison between extracorporeal shock
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11130
Yagisawa, T., Kobayashi, C., Ishikawa, N., Kobayashi, H., Toma, H. Benefits of ureteroscopic
pneumatic lithotripsy for the treatment of impacted ureteral stones Journal of Endourology. 2001;
15: 697-9
7441
Yang, S.S., Hong, J.S. Electrohydraulic lithotripsy of upper ureteral calculi with semirigid
ureteroscope Journal of Endourology. 1996; 10: 27-30
18600
Yaycioglu, O., Guvel, S., Kilinc, F., Egilmez, T., Ozkardes, H. Results with 7.5f Versus 10f rigid
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10065
Yeniyol, C.O., Ayder, A.R., Minareci, S., Cicek, S., Suelozgen, T. Comparision of intracorporeal
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18204
Yilmaz, E., Batislam, E., Basar, M. M., Tuglu, D., Ferhat, M., Basar, H. The comparison and
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2005; 173: 2010-2
19856
Yilmaz, E., Batislam, E., Basar, M., Tuglu, D., Mert, C., Basar, H. Optimal frequency in
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9422
Yinghao, S., Linhui, W., Songxi, Q., Guoqiang, L., Chuanliang, X., Xu, G., Yongjiang, M. Treatment
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8109
Yip, K.H., Lee, C.W., Tam, P.C. Holmium laser lithotripsy for ureteral calculi: an outpatient
procedure Journal of Endourology. 1998; 12: 241-246
7047
Yiu, M.K., Liu, P.L., Yiu, T.F., Chan, A.Y. Clinical experience with holmium:YAG laser lithotripsy of
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11132
Zargooshi, J. Open stone surgery in children: is it justified in the era of minimally invasive
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14424
Zeng, G. Q., Zhong, W. D., Cai, Y. B., Dai, Q. S., Hu, J. B., Wei, H. A. Extracorporeal shock-wave
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Andrology. 2002; 4: 303-5

32
Appendix 7: Bibliography of Extracted Articles Sorted

by ProCite Number
6359 Francesca, F., Grasso, M., Da Pozzo, L., Bertini, R., Nava, L., Rigatti, P. Ureteral Lithiasis: In situ
Piezoelectric versus in situ spark gap lithotripsy. A randomized study. Archivos Espanoles De Urologia. ; 48:
6420 Erhard, M., Salwen, J., Bagley, D.H. Ureteroscopic removal of mid and proximal ureteral calculi. Journal of
Urology. ; 155: 38-42
6425 Ozgur, S., Erol, A., Gunes, Z., Dalva, I., Cetin, S. Predictive value of a new scoring system for the outcome of
primary in situ experimental extracorporeal shock wave lithotripsy of upper ureteral calculi. European
6440 Scarpa, R.M., De Lisa, A., Porru, D., Canetto, A., Usai, E. Ureterolithotripsy in children. Urology. ; 46: 8596443 Nakada, S.Y., Pearle, M.S., Soble, J.J., Gardner, S.M., McClennan, B.L., Clayman, R.V. Extracorporeal
shock-wave lithotripsy of middle ureteral stones: are ureteral stents necessary?. Urology. ; 46: 649-652
6448 Francesca, F., Scattoni, V., Nava, L., Pompa, P., Grasso, M., Rigatti, P. Failures and complications of
transurethral ureteroscopy in 297 cases: conventional rigid instruments vs. small caliber semirigid
ureteroscopes. European Urology. ; 28: 112-115
6451 Laerum, E., Ommundsen, O.E., Gronseth, J.E., Christiansen, A., Fagertun, H.E. Oral diclofenac in the
prophylactic treatment of recurrent renal colic. A double-blind comparison with placebo. European Urology. ;
6472 Al-Rasheed, S.A., el-Faqih, S.R., Husain, I., Abdurrahman, M., al-Mugeirin, M.M. The aetiological and
clinical pattern of childhood urolithiasis in Saudi Arabia. International Urology & Nephrology. ; 27: 349-355
6480 Gade, J., Holtveg, H., Nielsen, O.S., Rasmussen, O.V. The treatment of ureteric calculi before and after the
introduction of extracorporeal shockwave lithotripsy. Scandinavian Journal of Urology & Nephrology. ; 29:
6481 Haupt, G., Pannek, J., Herde, T., Schulze, H., Senge, T. The Lithovac: new suction device for the Swiss
Lithoclast. Journal of Endourology. ; 9: 375-377
6490 Thuroff, S., Chaussy, C.G. First clinical experience and in situ treatment of ureteric stones using Lithostar
Multiline lithotripter. Journal of Endourology. ; 9: 367-370
6504 Scarpa, R.M., De Lisa, A., Usai, E. Diagnosis and treatment of ureteral calculi during pregnancy with rigid
ureteroscopes. Journal of Urology. ; 155: 875-877
6505 Schmidt, A., Volz, C., Eisenberger, F. The Dornier Lithotripter U 30: first clinical experience. Journal of
Endourology. ; 9: 363-366
6656 Carringer, M., Swartz, R., Johansson, J.E. Management of ureteric calculi during pregnancy by ureteroscopy
and laser lithotripsy. British Journal of Urology. ; 77: 17-20
6676 Kumar, V., Ahlawat, R., Banjeree, G.K., Bhaduria, R.P., Elhence, A., Bhandari, M. Percutaneous
ureterolitholapaxy: the best bet to clear large bulk impacted upper ureteral calculi. Archivos Espanoles De
6692 Smith, D.P., Jerkins, G.R., Noe, H.N. Urethroscopy in small neonates with posterior urethral valves and
ureteroscopy in children with ureteral calculi. Urology. ; 47: 908-910
6701 Lim, D.J., Walker, R.D., Ellsworth, P.I., Newman, R.C., Cohen, M.S., Barraza, M.A., Stevens, P.S. Treatment
of pediatric urolithiasis between 1984 and 1994. Journal of Urology. ; 156: 702-705
6716 Grasso, M. Experience with the holmium laser as an endoscopic lithotrite. Urology. ; 48: 199-206
6736 Razvi, H.A., Denstedt, J.D., Chun, S.S., Sales, J.L. Intracorporeal lithotripsy with the holmium:YAG laser.
Journal of Urology. ; 156: 912-914
6757 Hosking, D.H., Bard, R.J. Ureteroscopy with intravenous sedation for treatment of distal ureteral calculi: a safe
and effective alternative to shock wave lithotripsy. Journal of Urology. ; 156: 899-902
6899 Schow, D.A., Jackson, T.L., Samson, J.M., Hightower, S.A., Johnson, D.L. Use of intravenous alfentanilmidazolam anesthesia for sedation during brief endourologic procedures. Journal of Endourology. ; 8: 33-36
6947 Colombo, T., Zigeuner, R., Altziebler, S., Pummer, K., Stettner, H., Hubmer, G. Effect of extracorporeal shock
wave lithotripsy on prostate specific antigen. Journal of Urology. ; 156: 1682-1684

33
6957 Elashry, O.M., DiMeglio, R.B., Nakada, S.Y., McDougall, E.M., Clayman, R.V. Intracorporeal electrohydraulic
lithotripsy of ureteral and renal calculi using small caliber (1.9F) electrohydraulic lithotripsy probes. Journal
of Urology. ; 156: 1581-1585
6960 Geist, E., Schmidt, A., Volz, C., Eisenberger, F. The Dornier-Lithotripter U30. First clinical experience.
Archivos Espanoles De Urologia. ; 49: 437-441
6962 Gschwend, J.E., Haag, U., Hollmer, S., Kleinschmidt, K., Hautmann, R.E. Impact of extracorporeal shock
wave lithotripsy in pediatric patients: complications and long-term follow-up. Urologia Internationalis. ; 56:
6981 Terai, A., Takeuchi, H., Terachi, T., Kawakita, M., Okada, Y., Yoshida, H., Isokawa, Y., Taki, Y., Yoshida, O.
Intracorporeal lithotripsy with the Swiss Lithoclast. International Journal of Urology. ; 3: 184-186
7047 Yiu, M.K., Liu, P.L., Yiu, T.F., Chan, A.Y. Clinical experience with holmium:YAG laser lithotripsy of ureteral
calculi. Lasers In Surgery & Medicine. ; 19: 103-106
7096 Cranidis, A.I., Karayannis, A.A., Delakas, D.S., Livadas, C.E., Anezinis, P.E. Cystine stones: the efficacy of
percutaneous and shock wave lithotripsy. Urologia Internationalis. ; 56: 180-183
7100 Deliveliotis, C., Kostakopoulos, A., Stavropoulos, N.J., Koutsokalis, G., Dimopoulos, C. Extracorporeal shock
wave lithotripsy of middle ureteral calculi: ventral shock wave application. Urologia Internationalis. ; 56: 21-22
7111 Goethuys, H., Winnepenninckx, B., Van Poppel, H., Baert, L. The new generation Siemens Multiline
lithotripter tube M: early results in ureteral calculi. Journal of Endourology. ; 10: 403-406
7124 Jung, P., Wolff, J.M., Mattelaer, P., Jakse, G. Role of lasertripsy in the management of ureteral calculi:
experience with alexandrite laser system in 232 patients. Journal of Endourology. ; 10: 345-348
7129 Kurzrock, E.A., Huffman, J.L., Hardy, B.E., Fugelso, P. Endoscopic treatment of pediatric urolithiasis. Journal
of Pediatric Surgery. ; 31: 1413-1416
7140 Micali, S., Moore, R.G., Averch, T.D., Adams, J.B., Kavoussi, L.R. The role of laparoscopy in the treatment of
renal and ureteral calculi. Journal of Urology. ; 157: 463-466
7162 Shroff, S., Watson, G.M., Parikh, A., Thomas, R., Soonawalla, P.F., Pope, A. The holmium: YAG laser for
ureteric stones. British Journal of Urology. ; 78: 836-839
7170 Wolf, J.S., Jr., Bub, W.L., Endicott, R.C., Clayman, R.V. Use of intravenous contrast material during in situ
extracorporeal shock wave lithotripsy of ureteral calculi. Journal of Urology. ; 157: 38-41
7184 Cass, A.S. Comparison of first-generation (Dornier HM3) and second-generation (Medstone STS) lithotripters:
treatment results with 145 renal and ureteral calculi in children. Journal of Endourology. ; 10: 493-499
7187 Deliveliotis, C., Giannakopoulos, S., Louras, G., Koutsokalis, G., Alivizatos, G., Kostakopoulos, A. Doublepigtail stents for distal ureteral calculi: an alternative form of definitive treatment. Urologia Internationalis. ;
7198 Kim, H.H., Lee, J.H., Park, M.S., Lee, S.E., Kim, S.W. In situ extracorporeal shockwave lithotripsy for ureteral
calculi: investigation of factors influencing stone fragmentation and appropriate number of sessions for
changing treatment modality. Journal of Endourology. ; 10: 501-505
7227 Singal, R.K., Denstedt, J.D. Contemporary management of ureteral stones.. Urologic Clinics of North
America. ; 24: 59-70
7260 D'Amico, F.C., Belis, J.A. Treatment of ureteral calculi with an 8.3-Fr. disposable shaft rigid ureteroscope.
Techniques in Urology. ; 2: 126-129
7368 Deliveliotis, C., Stavropoulos, N.I., Koutsokalis, G., Kostakopoulos, A., Dimopoulos, C. Distal ureteral calculi:
ureteroscopy vs. ESWL. A prospective analysis. International Urology & Nephrology. ; 28: 627-631
7398 Kostakopoulos, A., Stavropoulos, N.J., Louras, G., Deliveliotis, C., Dimopoulos, C. Extracorporeal shock wave
lithotripsy of radiolucent urinary calculi using the Dornier HM-3 and HM-4 lithotriptors. Urologia
Internationalis. ; 58: 47-49
7408 Miroglu, C., Saporta, L. Transurethral ureteroscopy: is local anesthesia with intravenous sedation sufficiently
effective and safe?. European Urology. ; 31: 36-39

34
7416 Patel, A., Fuchs, G.J. Expanding the horizons of SWL through adjunctive use of retrograde intrarenal surgery:
new techniques and indications. Journal of Endourology. ; 11: 33-36
7441 Yang, S.S., Hong, J.S. Electrohydraulic lithotripsy of upper ureteral calculi with semirigid ureteroscope.
Journal of Endourology. ; 10: 27-30
7447 Netto, N.R., Claro, J.A., Esteves, S.C., Andrade, E.F. Ureteroscopic stone removal in the distal ureter. Why
change?. Journal of Urology. ; 157: 2081-2083
7469 Kim, S.C., Moon, Y.T. Experience with EDAP LT02 extracorporeal shockwave lithotripsy in 1363 patients:
comparison with results of LT01 SWL in 1586 patients. Journal of Endourology. ; 11: 103-111
7478 Minevich, E., Rousseau, M.B., Wacksman, J., Lewis, A.G., Sheldon, C.A. Pediatric ureteroscopy: technique
and preliminary results. Journal of Pediatric Surgery. ; 32: 571-574
7488 Tawfiek, E.R., Grasso, M., Bagley, D.H. Initial use of Browne Pneumatic Impactor. Journal of Endourology. ;
11: 121-124
7517 Doublet, J.D., Tchala, K., Tligui, M., Ciofu, C., Gattegno, B., Thibault, P. In situ extracorporeal shock wave
lithotripsy for acute renal colic due to obstructing ureteral stones. Scandinavian Journal of Urology &
7521 Denstedt, J.D., Chun, S.S., Miller, M.D., Eberwein, P.M. Intracorporeal lithotripsy with the Alexandrite laser.
Lasers In Surgery & Medicine. ; 20: 433-436
7532 Pearle, M.S., McClennan, B.L., Roehrborn, C.G., Clayman, R.V. Bolus injection v drip infusion contrast
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7725 Mathes, G.L., Jr., Mathes, L.T. High-energy v low-energy shockwave lithotripsy in treatment of ureteral
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7781 Bierkens, A.F., Hendrikx, A.J., De La Rosette, J.J., Stultiens, G.N., Beerlage, H.P., Arends, A.J., Debruyne,
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7805 Daehlin, L., Hellang, M., Ulvik, N.M. Shock wave lithotripsy of urinary calculi with Lithocut C-3000 in a small
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7858 Gould, D.L. Holmium:YAG laser and its use in the treatment of urolithiasis: our first 160 cases. Journal of
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7883 Nguyen, T.A., Belis, J.A. Endoscopic management of urolithiasis in the morbidly obese patient. Journal of
7909 Turk, I., Deger, S., Roigas, J., Fahlenkamp, D., Schonberger, B., Loening, S.A. Laparoscopic
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8008 Shokeir, A.A., Mutabagani, H. Rigid ureteroscopy in pregnant women. British Journal of Urology. ; 81: 678-681
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8036 Ghobish, A. In situ extracorporeal shockwave lithotripsy of middle and lower ureteral stones: a boosted,
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8066 Harmon, W.J., Sershon, P.D., Blute, M.L., Patterson, D.E., Segura, J.W. Ureteroscopy: current practice and
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8084 Huang, S., Patel, H., Bellman, G.C. Cost effectiveness of electrohydraulic lithotripsy v Candela pulsed-dye
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8164 Tan, P.K., Tan, S.M., Consigliere, D. Ureteroscopic lithoclast lithotripsy: a cost-effective option. Journal of
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8307 Tawfiek, E.R., Bagley, D.H. Management of upper urinary tract calculi with ureteroscopic techniques.
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8310 Wong, M.Y. Evolving technique of percutaneous nephrolithotomy in a developing country: Singapore
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8316 Larkin, G.L., Peacock, W.F., Pearl, S.M., Blair, G.A., D'Amico, F. Efficacy of ketorolac tromethamine versus
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8363 Hosking, D.H., McColm, S.E., Smith, W.E. Is stenting following ureteroscopy for removal of distal ureteral
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8376 Turk, T.M., Jenkins, A.D. A comparison of ureteroscopy to in situ extracorporeal shock wave lithotripsy for the
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8383 Elashry, O.M., Elbahnasy, A.M., Rao, G.S., Nakada, S.Y., Clayman, R.V. Flexible ureteroscopy: Washington
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8454 Beaghler, M., Poon, M., Ruckle, H., Stewart, S., Weil, D. Complications employing the holmium:YAG laser.
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8477 Lopez-Alcina, E., Broseta, E., Oliver, F., Boronat, F., Jimenez-Cruz, J.F. Paraureteral extrusion of calculi after
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8481 Reiter, W.J., Schon-Pernerstorfer, H., Dorfinger, K., Hofbauer, J., Marberger, M. Frequency of urolithiasis in
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8504 Ferraro, R.F., Abraham, V.E., Cohen, T.D., Preminger, G.M. A new generation of semirigid fiberoptic
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8517 Mahmood, N., Turner, W., Rowgaski, K., Almond, D. The patients perspective of extracorporeal shock wave
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8701 Robert, M., Rakotomalala, E., Delbos, O., Navratil, H. Piezoelectric lithotripsy of ureteral stones: influence of
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8788 Miller, O.F., Kane, C.J. Time to stone passage for observed ureteral calculi: a guide for patient education.

37
8793 Bendhack, M.L., Grimm, M.O., Ackermann, R., Vogeli, T. Primary treatment of ureteral stones by new
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8800 Fraser, M., Joyce, A.D., Thomas, D.F., Eardley, I., Clark, P.B. Minimally invasive treatment of urinary tract
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8812 Menezes, P., Dickinson, A., Timoney, A.G. Flexible ureterorenoscopy for the treatment of refractory upper
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8818 Richter, S., Shalev, M., Lobik, L., Buchumensky, V., Nissenkorn, I. Early postureteroscopy vesicoureteral
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8840 Karod, J.W., Danella, J., Mowad, J.J. Routine radiologic surveillance for obstruction is not required in
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8841 Maheshwari, P.N., Oswal, A.T., ankar, M., Nanjappa, K.M., Bansal, M. Is antegrade ureteroscopy better than
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8847 Robert, M., Lanfrey, P., Rey, G., Guiter, J., Navratil, H. Analgesia in piezoelectric SWL: comparative study of
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8956 Kourambas, J., Delvecchio, F. C., Preminger, G. M. Low-power holmium laser for the management of urinary
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9001 Reddy, P.P., Barrieras, D.J., Bagli, D.J., McLorie, G.A., Khoury, A.E., Merguerian, P.A. Initial experience with
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9036 Gnanapragasam, V.J., Ramsden, P.D., Murthy, L.S., Thomas, D.J. Primary in situ extracorporeal shock wave
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9051 Nualyong, C., Taweemonkongsap, T. Laparoscopic ureterolithotomy for upper ureteric calculi. Journal of the
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9057 Taari, K., Lehtoranta, K., Rannikko, S. Holmium:YAG laser for urinary stones. Scandinavian Journal of
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9092 Fuselier, H.A., Prats, L., Fontenot, C., Gauthier, A., Jr. Comparison of mobile lithotripters at one institution:
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9127 Virgili, G., Mearini, E., Micali, S., Miano, R., Vespasiani, G., Porena, M. Extracorporeal piezoelectric
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9256 Gross, A.J., Kugler, A., Seseke, F., Ringert, R.H. Push and smash increases success rates in treatment of
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9272 Matsuoka, K., Iida, S., Inoue, M., Yoshii, S., Arai, K., Tomiyasu, K., Noda, S. Endoscopic lithotripsy with the
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9275 Nakada, S.Y., Jerde, T.J., Bjorling, D.E., Saban, R. Selective cyclooxygenase-2 inhibitors reduce ureteral
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9312 Irving, S.O., Calleja, R., Lee, F., Bullock, K.N., Wraight, P., Doble, A. Is the conservative management of
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9391 Coz, F., Orvieto, M., Bustos, M., Lyng, R., Stein, C., Hinrichs, A., San Francisco, I. Extracorporeal shockwave
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9422 Yinghao, S., Linhui, W., Songxi, Q., Guoqiang, L., Chuanliang, X., Xu, G., Yongjiang, M. Treatment of
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9464 Nutahara, K., Kato, M., Miyata, A., Murata, A., Okegawa, T., Miura, I., Kojima, M., Higashihara, E.
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9469 Lorberboym, M., Kapustin, Z., Elias, S., Nikolov, G., Katz, R. The role of renal scintigraphy and unenhanced
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9526 Van Savage, J.G., Palanca, L.G., ersen, R.D., Rao, G.S., Slaughenhoupt, B.L. Treatment of distal ureteral
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9782 Pace, K.T., Weir, M.J., Tariq, N., Honey, R.J. Low success rate of repeat shock wave lithotripsy for ureteral
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9924 Li, J., Kennedy, D., Levine, M., Kumar, A., Mullen, J. Absent hematuria and expensive computerized
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10009 Landau, E.H., Gofrit, O.N., Shapiro, A., Meretyk, S., Katz, G., Shenfeld, O.Z., Golijanin, D., Pode, D.
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10522 Tiselius, H. G., Ackermann, D., Alken, P., Buck, C., Conort, P., Gallucci, M., Working Party on Lithiasis,
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10632 Hussain, Z., Inman, R. D., Elves, A. W., Shipstone, D. P., Ghiblawi, S., Coppinger, S. W. Use of glyceryl
trinitrate patches in patients with ureteral stones: a randomized, double-blind, placebo-controlled study.
10656 Hollenbeck, B. K., Schuster, T. G., Faerber, G. J., Wolf, J. S., Jr. Comparison of outcomes of ureteroscopy for
ureteral calculi located above and below the pelvic brim. Urology. ; 58: 351-6
10666 Pearle, M. S., Nadler, R., Bercowsky, E., Chen, C., Dunn, M., Figenshau, R. S., Hoenig, D. M., McDougall, E.
M., Mutz, J., Nakada, S. Y., Shalhav, A. L., Sundaram, C., Wolf, J. S., Clayman, R. V. Prospective
randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral
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really necessary?. Journal of Urology. ; 166: 1252-4
10696 Andreoni, C., Afane, J., Olweny, E., Clayman, R. V. Flexible ureteroscopic lithotripsy: first-line therapy for
proximal ureteral and renal calculi in the morbidly obese and superobese patient. Journal of Endourology. ;
10808 Sofer, M., Watterson, J. D., Wollin, T. A., Nott, L., Razvi, H., Denstedt, J. D. Holmium:YAG laser lithotripsy for
upper urinary tract calculi in 598 patients. Journal of Urology. ; 167: 31-4
10828 Coll, D. M., Varanelli, M. J., Smith, R. C. Relationship of spontaneous passage of ureteral calculi to stone
size and location as revealed by unenhanced helical CT. AJR. American Journal of Roentgenology. ; 178:
10892 Chang, C. P., Huang, S. H., Tai, H. L., Wang, B. F., Yen, M. Y., Huang, K. H., Jiang, H. J., Lin, J. Optimal
treatment for distal ureteral calculi: extracorporeal shockwave lithotripsy versus ureteroscopy. Journal of
10968 Sun, Y., Wang, L., Liao, G., Xu, C., Gao, X., Yang, Q., Qian, S. Pneumatic lithotripsy versus laser lithotripsy
in the endoscopic treatment of ureteral calculi. Journal of Endourology. ; 15: 587-90
11002 Picus, D., Weyman, P. J., Clayman, R. V., McClennan, B. L. Intercostal-space nephrostomy for percutaneous
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11010 Feyaerts, A., Rietbergen, J., Navarra, S., Vallancien, G., Guillonneau, B. Laparoscopic ureterolithotomy for
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11032 Peh, O. H., Lim, P. H., Ng, F. C., Chin, C. M., Quek, P., Ho, S. H. Holmium laser lithotripsy in the
management of ureteric calculi.. Annals of the Academy of Medicine, Singapore. ; 30: 563-7
11038 Taylor, A. L., Oakley, N., Das, S., Parys, B. T. Day-case ureteroscopy: an observational study.. Bju
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11058 Delakas, D., Daskalopoulos, G., Metaxari, M., Triantafyllou, T., Cranidis, A. Management of ureteral stones in
pediatric patients. Journal of Endourology. ; 15: 675-80
11066 Eichel, L., Batzold, P., Erturk, E. Operator experience and adequate anesthesia improve treatment outcome
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11130 Yagisawa, T., Kobayashi, C., Ishikawa, N., Kobayashi, H., Toma, H. Benefits of ureteroscopic pneumatic
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11132 Zargooshi, J. Open stone surgery in children: is it justified in the era of minimally invasive therapies?. Bju
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11156 Goel, A., Hemal, A. K. Upper and mid-ureteric stones: a prospective unrandomized comparison of
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41
11176 Martinez Portillo, F. J., Heidenreich, A., Schwarzer, U., Michel, M. S., Alken, P., Engelmann, U. Microscopic
and biochemical fertility characteristics of semen after shockwave lithotripsy of distal ureteral calculi. Journal
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11196 Redman, J. F., Reddy, P. P. Outcomes analysis of 64 consecutive open pediatric renal and upper ureteral
operations. Urology. ; 59: 588-90; discussion 590
11200 Sayed, M. A, el-Taher, A..M., Aboul-Ella, H. A., Shaker, S. E. Steinstrasse after extracorporeal shockwave
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11216 Desai, M. R., Patel, S. B., Desai, M. M., Kukreja, R., Sabnis, R. B., Desai, R. M., Patel, S. H. The Dretler
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11228 Schuster, T. G., Russell, K. Y., Bloom, D. A., Koo, H. P., Faerber, G. J. Ureteroscopy for the treatment of
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11234 Lotan, Y., Gettman, M. T., Roehrborn, C. G., Cadeddu, J. A., Pearle, M. S. Management of ureteral calculi:
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11254 Bugg, C. E. Jr., El-Galley, R., Kenney, P. J., Burns, J. R. Follow-up functional radiographic studies are not
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11368 Gaur, D. D., Trivedi, S., Prabhudesai, M. R., Madhusudhana, H. R., Gopichand, M. Laparoscopic
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11460 Rodrigues Netto, N., Jr., Longo, J. A., Ikonomidis, J. A., Rodrigues Netto, M. Extracorporeal shock wave
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11472 Chandhoke, P. S., Barqawi, A. Z., Wernecke, C., Chee-Awai, R. A. A randomized outcomes trial of ureteral
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11474 Chen, Y. T., Chen, J., Wong, W. Y., Yang, S. S., Hsieh, C. H., Wang, C. C. Is ureteral stenting necessary after
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11476 Lam, J. S., Greene, T. D., Gupta, M. Treatment of proximal ureteral calculi: holmium:yag laser
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11630 Lingeman, J.E., Preminger, G.M., Berger, Y., Denstedt, J.D., Goldstone, L., Segura, J.W., Auge, B.K.,
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11640 Porpiglia, F., Destefanis, P., Fiori, C., Scarpa, R. M., Fontana, D. Role of adjunctive medical therapy with
nifedipine and deflazacort after extracorporeal shock wave lithotripsy of ureteral stones.. Urology. ; 59: 835-8
11672 Skrepetis, K., Doumas, K., Siafakas, I., Lykourinas, M. Laparoscopic versus open ureterolithotomy. A
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11760 Bassiri, A., Ahmadnia, H., Darabi, M. R., Yonessi, M. Transureteral lithotripsy in pediatric practice.. Journal of
11778 Buchholz, N. P., Rhabar, M. H., Talati, J. Is measurement of stone surface area necessary for SWL treatment
of nonstaghorn calculi?.. Journal of Endourology. ; 16: 215-20
11806 Parkin, J., Keeley, F. X., Jr, Timoney, A. G. Re-auditing a regional lithotripsy service.. BJU International. ;
11960 Weizer, A. Z., Auge, B. K., Silverstein, A. D., Delvecchio, F. C., Brizuela, R. M., Dahm, P., Pietrow, P. K.,
Lewis, B. R., Albala, D. M., Preminger, G. M. Routine postoperative imaging is important after ureteroscopic
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12030 Paryani, J. P., Ather, M. H. Improvement in serum creatinine following definite treatment of urolithiasis in
patients with concurrent renal insufficiency.. Scandinavian Journal of Urology & Nephrology. ; 36: 134-6
12032 Byrne, R. R., Auge, B. K., Kourambas, J., Munver, R., Delvecchio, F., Preminger, G. M. Routine ureteral
stenting is not necessary after ureteroscopy and ureteropyeloscopy: a randomized trial.. Journal of

42
12094 Volkmer, B. G., Nesslauer, T., Kuefer, R., Loeffler, M., Kraemer, S. C., Gottfried, H. W. Evaluation of
disintegration in prevesical ureteral calculi by 3-dimensional endo-ultrasound with surface rendering..
12096 Jermini, F. R., Danuser, H., Mattei, A., Burkhard, F. C., Studer, U. E. Noninvasive anesthesia, analgesia and
radiation-free extracorporeal shock wave lithotripsy for stones in the most distal ureter: experience with 165
patients.. Journal of Urology. ; 168: 446-9
12404 Lifshitz, D. A., Lingeman, J. E. Ureteroscopy as a first-line intervention for ureteral calculi in pregnancy..
12452 Azm, T. A., Higazy, H. Effect of diuresis on extracorporeal shockwave lithotripsy treatment of ureteric calculi..
Scandinavian Journal of Urology & Nephrology. ; 36: 209-12
12508 Aynehchi, S., Samadi, A. A., Gallo, S. J., Konno, S., Tazaki, H., Eshghi, M. Salvage extracorporeal
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12754 Dash, A., Schuster, T. G., Hollenbeck, B. K., Faerber, G. J., Wolf, J. S., Jr Ureteroscopic treatment of renal
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12756 Shoma, A. M., Eraky, I., El-Kenawy, M. R., El-Kappany, H. A. Percutaneous nephrolithotomy in the supine
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12758 Watterson, J. D., Girvan, A. R., Beiko, D. T., Nott, L., Wollin, T. A., Razvi, H., Denstedt, J. D. Ureteroscopy and
holmium:yag laser lithotripsy: an emerging definitive management strategy for symptomatic ureteral calculi
in pregnancy.. Urology. ; 60: 383-7
12788 Shiroyanagi, Y., Yagisawa, T., Nanri, M., Kobayashi, C., Toma, H. Factors associated with failure of
extracorporeal shock-wave lithotripsy for ureteral stones using dornier lithotripter u/50.. International Journal
12882 Portis, A. J., Yan, Y., Pattaras, J. G., Andreoni, C., Moore, R., Clayman, R. V. Matched pair analysis of shock
wave lithotripsy effectiveness for comparison of lithotriptors.[Comment].. Journal of Urology. ; 169: 58-62
13040 Loughlin, K. R., Ker, L. A. The current management of urolithiasis during pregnancy.. Urologic Clinics of
North America. ; 29: 701-4
13042 Perisinakis, K., Damilakis, J., Anezinis, P., Tzagaraki, I., Varveris, H., Cranidis, A., Gourtsoyiannis, N.
Assessment of patient effective radiation dose and associated radiogenic risk from extracorporeal shock-wave
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13190 Hochreiter, W. W., Danuser, H., Perrig, M., Studer, U. E. Extracorporeal shock wave lithotripsy for distal
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13210 Rizvi, S. A., Naqvi, S. A., Hussain, Z., Hashmi, A., Hussain, M., Zafar, M. N., Sultan, S., Mehdi, H.
Management of pediatric urolithiasis in pakistan: experience with 1,440 children.. Journal of Urology. ; 169:
13218 Hemal, A. K., Goel, A., Goel, R. Minimally invasive retroperitoneoscopic ureterolithotomy.. Journal of
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13256 Lalak, N. J., Moussa, S. A., Smith, G., Tolley, D. A. The Dornier Compact Delta lithotripter: The first 150
ureteral calculi.. Journal of Endourology. ; 16: 645-8
13262 Tan, Y. M., Yip, S. K., Chong, T. W., Wong, M. Y., Cheng, C., Foo, K. T. Clinical experience and results of
ESWL treatment for 3,093 urinary calculi with the Storz Modulith SL20 lithotripter at the Singapore General
Hospital.. Scandinavian Journal of Urology & Nephrology. ; 36: 363-7
13596 Cheung, M. C., Lee, F., Leung, Y. L., Wong, B. B., Tam, P. C. A prospective randomized controlled trial on
ureteral stenting after ureteroscopic holmium laser lithotripsy.. Journal of Urology. ; 169: 1257-60
13620 Lewis, D. F., Robichaux, A. G., 3rd, Jaekle, R. K., Marcum, N. G., Stedman, C. M. Urolithiasis in pregnancy.
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13914 Delvecchio, F. C., Auge, B. K., Brizuela, R. M., Weizer, A. Z., Silverstein, A. D., Lallas, C. D., Pietrow, P. K.,
Albala, D. M., Preminger, G. M. Assessment of stricture formation with the ureteral access sheath.. Urology. ;
14074 Hollenbeck, B. K., Schuster, T. G., Seifman, B. D., Faerber, G. J., Wolf, J. S., Jr. Identifying patients who are
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43
14076 Chow, G. K., Patterson, D. E., Blute, M. L., Segura, J. W. Ureteroscopy: Effect of technology and technique
on clinical practice.. Journal of Urology. ; 170: 99-102
14212 Pietrow, P. K., Auge, B. K., Delvecchio, F. C., Silverstein, A. D., Weizer, A. Z., Albala, D. M., Preminger, G.
M. Techniques to maximize flexible ureteroscope longevity.. Urology. ; 60: 784-8
14256 Sheir, K. Z., Madbouly, K., Elsobky, E. Prospective randomized comparative study of the effectiveness and
safety of electrohydraulic and electromagnetic extracorporeal shock wave lithotriptors.. Journal of Urology. ;
14286 Delakas, D., Karyotis, I., Daskalopoulos, G., Lianos, E., Mavromanolakis, E. Independent predictors of failure
of shockwave lithotripsy for ureteral stones employing a second-generation lithotripter.. Journal of
14292 Klingler, H. C., Kramer, G., Lodde, M., Dorfinger, K., Hofbauer, J., Marberger, M. Stone treatment and
coagulopathy.. European Urology. ; 43: 75-9
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14424 Zeng, G. Q., Zhong, W. D., Cai, Y. B., Dai, Q. S., Hu, J. B., Wei, H. A. Extracorporeal shock-wave versus
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14430 Arrabal-Martin, M., Pareja-Vilches, M., Gutierrez-Tejero, F., Mijan-Ortiz, J. L., Palao-Yago, F., ZuluagaGomez, A. Therapeutic options in lithiasis of the lumbar ureter.. European Urology. ; 43: 556-63
14432 Tligui, M., El Khadime, M. R., Tchala, K., Haab, F., Traxer, O., Gattegno, B., Thibault, P. Emergency
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14500 Deliveliotis, C., Chrisofos, M., Albanis, S., Serafetinides, E., Varkarakis, J., Protogerou, V. Management and
follow-up of impacted ureteral stones.. Urologia Internationalis. ; 70: 269-72
14548 Cervenakov, I., Fillo, J., Mardiak, J., Kopecny, M., Smirala, J., Lepies, P. Speedy elimination of
ureterolithiasis in lower part of ureters with the alpha 1-blocker--tamsulosin.. International Urology &
14560 Hosking, D. H., Smith, W. E., McColm, S. E. A comparison of extracorporeal shock wave lithotripsy and
ureteroscopy under intravenous sedation for the management of distal ureteric calculi.. Canadian Journal of
14600 Johnson, D. B., Lowry, P. S., Schluckebier, J. A., Kryger, J. V., Nakada, S. Y. University of Wisconsin
experience using the Doli S lithotriptor.. Urology. ; 62: 410-4; discussion 414-5
14620 Knopf, H. J., Graff, H. J., Schulze, H. Perioperative antibiotic prophylaxis in ureteroscopic stone removal..
European Urology. ; 44: 115-8
14632 Sharma, D. M., Maharaj, D., Naraynsingh, V. Open mini-access ureterolithotomy: the treatment of choice for
the refractory ureteric stone?.. BJU International. ; 92: 614-6
14766 Nelson, C. P., Wolf, J. S., Jr., Montie, J. E., Faerber, G. J. Retrograde ureteroscopy in patients with orthotopic
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14954 Slavkovic, A., Radovanovic, M., Siric, Z., Vlajkovic, M., Stefanovic, V. Extracorporeal shock wave lithotripsy
for cystine urolithiasis in children: outcome and complications.. International Urology & Nephrology. ; 34:
15058 Troy, A., Jones, G., Moussa, S. A., Smith, G., Tolley, D. A. Treatment of lower ureteral stones using the
Dornier Compact Delta lithotripter.. Journal of Endourology. ; 17: 369-71
15096 Mugiya, S., Ito, T., Maruyama, S., Hadano, S., Nagae, H. Endoscopic features of impacted ureteral stones..
15138 Ege, G., Akman, H., Kuzucu, K., Yildiz, S. Acute ureterolithiasis: incidence of secondary signs on
unenhanced helical ct and influence on patient management.. Clinical Radiology. ; 58: 990-4
15146 Muslumanoglu, A. Y., Tefekli, A., Sarilar, O., Binbay, M., Altunrende, F., Ozkuvanci, U. Extracorporeal shock
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retrospective analysis.. Journal of Urology. ; 170: 2405-8
15156 Dellabella, M., Milanese, G., Muzzonigro, G. Efficacy of tamsulosin in the medical management of
juxtavesical ureteral stones.. Journal of Urology. ; 170: 2202-5

44
15174 Ozgur Tan, M., Karaoglan, U., Sozen, S., Bozkirli, I. Extracorporeal shock-wave lithotripsy for treatment of
ureteral calculi in paediatric patients.. Pediatric Surgery International. ; 19: 471-4
15198 Johnson, G. B., Grasso, M. Exaggerated primary endoscope deflection: initial clinical experience with
prototype flexible ureteroscopes.. BJU International. ; 93: 109-14
15226 Nabi, G., Baldo, O., Cartledge, J., Cross, W., Joyce, A. D., Lloyd, S. N. The impact of the Dornier Compact
Delta lithotriptor on the management of primary ureteric calculi.. European Urology. ; 44: 482-6
15418 Erbagci, A., Erbagci, A. B., Yilmaz, M., Yagci, F., Tarakcioglu, M., Yurtseven, C., Koyluoglu, O., Sarica, K.
Pediatric urolithiasis--evaluation of risk factors in 95 children.. Scandinavian Journal of Urology &
15490 Gronau, E., Pannek, J., Bohme, M., Senge, T. Results of extracorporeal shock wave lithotripsy with a new
electrohydraulic shock wave generator.. Urologia Internationalis. ; 71: 355-60
15558 Kose, A. C., Demirbas, M. The 'modified prone position': A new approach for treating pre-vesical stones with
extracorporeal shock wave lithotripsy.. BJU International. ; 93: 369-73
15572 Abdel-Khalek, M., Sheir, K., Elsobky, E., Showkey, S., Kenawy, M. Prognostic factors for extracorporeal shockwave lithotripsy of ureteric stones--A multivariate analysis study.. Scandinavian Journal of Urology &
15606 Aghamir, S. K., Mohseni, M. G., Ardestani, A. Treatment of ureteral calculi with ballistic lithotripsy.. Journal
15608 Hollenbeck, B. K., Schuster, T. G., Faerber, G. J., Wolf, J. S., Jr. Safety and efficacy of same-session bilateral
ureteroscopy.. Journal of Endourology. ; 17: 881-5
15612 Srivastava, A., Gupta, R., Kumar, A., Kapoor, R., Mandhani, A. Routine stenting after ureteroscopy for distal
ureteral calculi is unnecessary: results of a randomized controlled trial.. Journal of Endourology. ; 17: 871-4
15616 Cimentepe, E., Unsal, A., Saglam, R., Balbay, M. D. Comparison of clinical outcome of extracorporeal
shockwave lithotripsy in patients with radiopaque v radiolucent ureteral calculi.. Journal of Endourology. ; 17:
15624 Katz, D., McGahan, J. P., Gerscovich, E. O., Troxel, S. A., Low, R. K. Correlation of ureteral stone
measurements by CT and plain film radiography: Utility of the KUB.. Journal of Endourology. ; 17: 847-50
15652 Parekattil, S. J., White, M. D., Moran, M. E., Kogan, B. A. A computer model to predict the outcome and
duration of ureteral or renal calculous passage.. Journal of Urology. ; 171: 1436-9
15748 Fong, Y. K., Ho, S. H., Peh, O. H., Ng, F. C., Lim, P. H., Quek, P. L., Ng, K. K. Extracorporeal shockwave
lithotripsy and intracorporeal lithotripsy for proximal ureteric calculi--A comparative assessment of efficacy
and safety.. Annals of the Academy of Medicine, Singapore. ; 33: 80-3
15756 Bultitude, M. F., Tiptaft, R. C., Dasgupta, P., Glass, J. M. Treatment of urolithiasis in the morbidly obese..
Obesity Surgery. ; 14: 300-4
15766 Holman, E., Khan, A. M., Flasko, T., Toth, C., Salah, M. A. Endoscopic management of pediatric urolithiasis
in a developing country.. Urology. ; 63: 159-62
15778 char, E., Achar, R. A., Paiva, T. B., Campos, A. H., Schor, N. Amitriptyline eliminates calculi through urinary
tract smooth muscle relaxation.. Kidney International. ; 64: 1356-64
15788 Tansu, N., Obek, C., Onal, B., Yalcin, V., Oner, A., Solok, V. A simple position to provide better imaging of
upper ureteral stones close to the crista iliaca during extracorporeal shock wave lithotripsy using the Siemens
Lithostar.. European Urology. ; 45: 352-5
15796 Jeong, H., Kwak, C., Lee, S. E. Ureteric stenting after ureteroscopy for ureteric stones: a prospective
randomized study assessing symptoms and complications.. BJU International. ; 93: 1032-35
15798 Collins, J. W., Keeley, F. X., Jr, Timoney, A. Cost analysis of flexible ureterorenoscopy.. BJU International. ;
15852 Auge, B. K., Pietrow, P. K., Lallas, C. D., Raj, G. V., Santa-Cruz, R. W., Preminger, G. M. Ureteral access
sheath provides protection against elevated renal pressures during routine flexible ureteroscopic stone
manipulation.. Journal of Endourology. ; 18: 33-6

45
15862 Jain, P. M., Goharian, N., Weiser, A. C., User, H. M., Kimm, S., Kim, S. C., Stern, J. A., Pazona, J., Wambi,
C., Yap, R., Blunt, L. W., Nadler, R. B. Efficacy and safety of the Healthtronics Lithotron lithotripter.. Journal
15872 Ansari, M. S., Gupta, N. P., Seth, A., Hemal, A. K., Dogra, P. N., Singh, T. P. Stone fragility: its therapeutic
implications in shock wave lithotripsy of upper urinary tract stones.. International Urology & Nephrology. ; 35:
15976 Beiko, D. T., Beasley, K. A., Koka, P. K., Watterson, J. D., Nott, L., Denstedt, J. D., Razvi, H. Upper tract
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15978 McLorie, G. A., Pugach, J., Pode, D., Denstedt, J., Bagli, D., Meretyk, S., D'A Honey, R. J., Merguerian, P. A.,
Shapiro, A., Khoury, A. E., Landau, E. H. Safety and efficacy of extracorporeal shock wave lithotripsy in
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16010 Sozen, S., Kupeli, B., Tunc, L., Senocak, C., Alkibay, T., Karaoglan, U., Bozkirli, I. Management of ureteral
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16028 Varkarakis, J., Protogerou, V., Albanis, S., Sofras, F., Deliveliotis, C. Comparison of success rates and
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16046 Al-Busaidy, S. S., Prem, A. R., Medhat, M., Al-Bulushi, Y. H. Ureteric calculi in children: Preliminary
experience with holmium:yag laser lithotripsy.. BJU International. ; 93: 1318-23
16098 Gur, U., Lifshitz, D. A., Lask, D., Livne, P. M. Ureteral ultrasonic lithotripsy revisited: a neglected tool?.
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16128 Purohit, R. S., Stoller, M. L. Stone clustering of patients with cystine urinary stone formation.. Urology. ; 63:
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16272 Satar, N., Zeren, S., Bayazit, Y., Aridogan, I. A., Soyupak, B., Tansug, Z. Rigid ureteroscopy for the treatment
of ureteral calculi in children.. Journal of Urology. ; 172: 298-300
16284 Gomha, M. A., Sheir, K. Z., Showky, S., Abdel-Khalek, M., Mokhtar, A. A., Madbouly, K. Can we improve the
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or a statistical model?.. Journal of Urology. ; 172: 175-9
16332 Porpiglia, F., Ghignone, G., Fiori, C., Fontana, D., Scarpa, R. M. Nifedipine versus tamsulosin for the
management of lower ureteral stones.. Journal of Urology. ; 172: 568-71
16366 Dogan, H. S., Tekgul, S., Akdogan, B., Keskin, M. S., Sahin, A. Use of the holmium:yag laser for
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16394 De Sio, M., Autorino, R., Damiano, R., Oliva, A., Pane, U., D'Armiento, M. Expanding applications of the
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16396 De Sio, M., Autorino, R., Damiano, R., Oliva, A., Perdona, S., D'Armiento, M. Comparing two different
ballistic intracorporeal lithotripters in the management of ureteral stones.. Urologia Internationalis.. ; 72: 52-52
16398 Di Pietro, C., Micali, S., De Stefani, S., Celia, A., De Carne, C., Bianchi, G. Dornier Lithotripter S. The first
50 treatments in our department.. Urologia Internationalis.. ; 72: 48-5
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16438 Park, H. K., Paick, S. H., Oh, S. J., Kim, H. H. Ureteroscopic lithotripsy under local anesthesia: Analysis of the
effectiveness and patient tolerability.. European Urology. ; 45: 670-3
16600 Sinha, M., Kekre, N. S., Chacko, K. N., Devasia, A., Lionel, G., Pandey, A. P., Gopalakrishnan, G. Does
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46
17092 Butler, M. R., Power, R. E., Thornhill, J. A., Ahmad, I., McLornan, I., McDermott, T., Grainger, R. An audit of
2273 ureteroscopies--A focus on intra-operative complications to justify proactive management of ureteric
calculi.. Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland. ; 2: 42-6
17104 Wu, C. F., Shee, J. J., Lin, W. Y., Lin, C. L., Chen, C. S. Comparison between extracorporeal shock wave
lithotripsy and semirigid ureterorenoscope with holmium:YAG laser lithotripsy for treating large proximal
ureteral stones.. Journal of Urology. ; 172: 1899-902
17108 Ng, C. F., McLornan, L., Thompson, T. J., Tolley, D. A. Comparison of 2 generations of piezoelectric
lithotriptors using matched pair analysis.. Journal of Urology. ; 172: 1887-91
17128 Akhtar, M. S., Akhtar, F. K. Utility of the Lithoclast in the treatment of upper, middle and lower ureteric
calculi.. Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland. ; 1: 144-8
17168 Lee, W. C., Hsieh, H. H. Retroperitoneoscopic ureterolithotomy for impacted ureteral stones.. Chang Gung
Medical Journal. ; 23: 28-32
17218 Dasgupta, P., Cynk, M. S., Bultitude, M. F., Tiptaft, R. C., Glass, J. M. Flexible ureterorenoscopy: prospective
analysis of the Guy's experience.. Annals of the Royal College of Surgeons of England. ; 86: 367-70
17392 Marguet, C. G., Springhart, W. P., Auge, B. K., Preminger, G. M. Advances in the surgical management of
nephrolithiasis.. Minerva Urologica e Nefrologica. ; 56: 33-48
17432 Wang, L. J., Ng, C. J., Chen, J. C., Chiu, T. F., Wong, Y. C. Diagnosis of acute flank pain caused by ureteral
stones: value of combined direct and indirect signs on IVU and unenhanced helical CT.. European
17436 Damiano, R., Autorino, R., Esposito, C., Cantiello, F., Sacco, R., de Sio, M., D'Armiento, M. Stent positioning
after ureteroscopy for urinary calculi: The question is still open.. European Urology. ; 46: 381-88
17528 Cybulski, P., Honey, R. J., Pace, K. Fluid absorption during ureterorenoscopy.. Journal of Endourology. ; 18:
17558 Maislos, S. D., Volpe, M., Albert, P. S., Raboy, A. Efficacy of the stone cone for treatment of proximal
ureteral stones.. Journal of Endourology. ; 18: 862-4
17742 Koroglu, M., Wendel, J. D., Ernst, R. D., Oto, A. Alternative diagnoses to stone disease on unenhanced CT to
investigate acute flank pain.. . ; 10: 327-33
17748 Nouira, Y., Kallel, Y., Binous, M. Y., Dahmoul, H., Horchani, A. Laparoscopic retroperitoneal
ureterolithotomy: initial experience and review of literature. [Review] [21 refs]. Journal of Endourology. ; 18:
17762 Tan, A. H., Al-Omar, M., Watterson, J. D., Nott, L., Denstedt, J. D., Razvi, H. Results of shockwave lithotripsy
for pediatric urolithiasis.. Journal of Endourology. ; 18: 527-30
17810 Sheir, K. Z., El-Diasty, T. A., Ismail, A. M. Evaluation of a synchronous twin-pulse technique for shock wave
lithotripsy: The first prospective clinical study.. BJU International. ; 95: 389-93
17838 Hautmann, S., Friedrich, M. G., Fernandez, S., Steuber, T., Hammerer, P., Braun, P. M., Junemann, K. P.,
Huland, H. Extracorporeal shockwave lithotripsy compared with ureteroscopy for the removal of small distal
ureteral stones.. Urologia Internationalis. ; 73: 238-43
17840 Demirci, D., Gulmez, I., Ekmekcioglu, O., Karacagil, M. Retroperitoneoscopic ureterolithotomy for the
treatment of ureteral calculi.. Urologia Internationalis. ; 73: 234-7
18052 De Dominicis, M., Matarazzo, E., Capozza, N., Collura, G., Caione, P. Retrograde ureteroscopy for distal
ureteric stone removal in children.. BJU International. ; 95: 1049-52
18054 Hudson, R. G., Conlin, M. J., Bagley, D. H. Ureteric access with flexible ureteroscopes: Effect of the size of
the ureteroscope.. BJU International. ; 95: 1043-4
18116 Raza, A., Smith, G., Moussa, S., Tolley, D. Ureteroscopy in the management of pediatric urinary tract
calculi.. Journal of Endourology. ; 19: 151-8
18152 Goel, R., Aron, M., Kesarwani, P. K., Dogra, P. N., Hemal, A. K., Gupta, N. P. Percutaneous antegrade
removal of impacted upper-ureteral calculi: Still the treatment of choice in developing countries.. Journal of

47
18154 Aridogan, I. A., Zeren, S., Bayazit, Y., Soyupak, B., Doran, S. Complications of pneumatic ureterolithotripsy
in the early postoperative period.. Journal of Endourology. ; 19: 50-3
18174 Kravchick, S., Bunkin, I., Stepnov, E., Peled, R., Agulansky, L., Cytron, S. Emergency extracorporeal
shockwave lithotripsy for acute renal colic caused by upper urinary-tract stones.. Journal of Endourology. ; 19:
18204 Yilmaz, E., Batislam, E., Basar, M. M., Tuglu, D., Ferhat, M., Basar, H. The comparison and efficacy of 3
different alpha1-adrenergic blockers for distal ureteral stones.. Journal of Urology. ; 173: 2010-2
18376 Unsal, A., Cimentepe, E., Balbay, M. D. Routine ureteral dilatation is not necessary for ureteroscopy..
International Urology & Nephrology. ; 36: 503-6
18400 Minevich, E., Defoor, W., Reddy, P., Nishinaka, K., Wacksman, J., Sheldon, C., Erhard, M. Ureteroscopy is
safe and effective in prepubertal children.. Journal of Urology. ; 174: 276-9; discussion 279
18402 Dellabella, M., Milanese, G., Muzzonigro, G. Randomized trial of the efficacy of tamsulosin, nifedipine and
phloroglucinol in medical expulsive therapy for distal ureteral calculi.. Journal of Urology. ; 174: 167-72
18474 Dagnone, A. J., Blew, B. D., Pace, K. T., Honey, R. J. Semirigid ureteroscopy of the proximal ureter can be
aided by external lower-abdominal pressure.. Journal of Endourology. ; 19: 342-7
18522 Kupeli, B., Irkilata, L., Gurocak, S., Tunc, L., Kirac, M., Karaoglan, U., Bozkirli, I. Does tamsulosin enhance
lower ureteral stone clearance with or without shock wave lithotripsy?.. Urology. ; 64: 1111-5
18524 Parker, B. D., Frederick, R. W., Reilly, T. P., Lowry, P. S., Bird, E. T. Efficiency and cost of treating proximal
ureteral stones: Shock wave lithotripsy versus ureteroscopy plus holmium:yttrium-aluminum-garnet laser..
Urology. ; 64: 1102-6; discussion 1106
18552 Pardalidis, N. P., Papatsoris, A. G., Kosmaoglou, E. V. Prevention of retrograde calculus migration with the
stone cone.. Urological Research. ; 33: 61-4
18576 Soares, R. S., Romanelli, P., Sandoval, M. A., Salim, M. M., Tavora, J. E., Abelha, D. L., Jr.
Retroperitoneoscopy for treatment of renal and ureteral stones.. International Braz J Urol. ; 31: 111-6
18600 Yaycioglu, O., Guvel, S., Kilinc, F., Egilmez, T., Ozkardes, H. Results with 7.5f Versus 10f rigid ureteroscopes
in treatment of ureteral calculi.. Urology. ; 64: 643-7
18658 Monga, M., Best, S., Venkatesh, R., Ames, C., Lieber, D., Vanlangendock, R., Landman, J. Prospective
randomized comparison of 2 ureteral access sheaths during flexible retrograde ureteroscopy.. Journal of
18718 Ng CF, McLornan L, Thompson TJ, Tolley DA Comparison of 2 generations of piezoelectric lithotriptors using
matched pair analysis.. Journal of Urology. ; 172: 1887-91
18906 Hsu, J. M., Chen, M., Lin, W. C., Chang, H. K., Yang, S. Ureteroscopic management of sepsis associated with
ureteral stone impaction: Is it still contraindicated?.. Urologia Internationalis. ; 74: 319-22
18914 Tan, A. H., Al-Omar, M., Denstedt, J. D., Razvi, H. Ureteroscopy for pediatric urolithiasis: An evolving first-line
therapy.. Urology. ; 65: 153-6
18928 Raza, A., Turna, B., Smith, G., Moussa, S., Tolley, D. A. Pediatric urolithiasis: 15 years of local experience
with minimally invasive endourological management of pediatric calculi.. Journal of Urology. ; 174: 682-5
18958 Albala, D. M., Siddiqui, K. M., Fulmer, B., Alioto, J., Frankel, J., Monga, M. Extracorporeal shock wave
lithotripsy with a transportable electrohydraulic lithotripter: experience with >300 patients.. BJU International.
18970 Hubert, K. C., Palmer, J. S. Passive dilation by ureteral stenting before ureteroscopy: eliminating the need
for active dilation.. Journal of Urology. ; 174: 1079-80
18972 Thomas, J. C., DeMarco, R. T., Donohoe, J. M., Adams, M. C., Brock, J. W., 3rd, Pope, J. C, 4th Pediatric
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evaluation of emergency extracorporeal shock wave lithotripsy (eswl) on the short-time outcome of
symptomatic ureteral stones.. European Urology. ; 47: 855-9

48
19044 Tiselius, H. G. Removal of ureteral stones with extracorporeal shock wave lithotripsy and ureteroscopic
procedures. What can we learn from the literature in terms of results and treatment efforts?.. Urological
19204 Jeon, S. S., Hyun, J. H., Lee, K. S. A comparison of holmium:yag laser with lithoclast lithotripsy in ureteral
calculi fragmentation.. International Journal of Urology. ; 12: 544-7
19764 Resim, S., Ekerbicer, H. C., Ciftci, A. Role of tamsulosin in treatment of patients with steinstrasse developing
after extracorporeal shock wave lithotripsy.. Urology. ; 66: 945-8
19818 Resim, S., Ekerbicer, H., Ciftci, A. Effect of tamsulosin on the number and intensity of ureteral colic in
patients with lower ureteral calculus.. International Journal of Urology. ; 12: 615-20
19854 Akhtar, S., Ather, M. H. Appropriate cutoff for treatment of distal ureteral stones by single session in situ
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19856 Yilmaz, E., Batislam, E., Basar, M., Tuglu, D., Mert, C., Basar, H. Optimal frequency in extracorporeal shock
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holmium:yttrium-aluminum-garnet laser lithotripsy. Urology. ; 65: 1075-9

49
Appendix 8: Stone Free Rates for Observation

Therapies by Size
A special analysis of observation therapies was requested for stone sizes of <5, 5-10,
and >10 mm stones. Most studies didnt fit these ranges. Below is the analysis that was
possible.
Observation
Article # # Stone free
# pts
Notes
<5 mm
8788
9526
10632
10828
18522
54
12
9
85
3
68% (46 - 85)%
59
27
9
114
15
8788
10632
10828
8
9
31
47% (36 - 59)%
16
15
73
Meta-analysis:
4mm or less
results at 2 weeks
5-10mm
Meta-analysis:
<10mm - not falling into above classes

9663
19
14548
32
Meta-analysis:
59% (45 - 72)%
>10 mm
35
51
>4 mm
Results at 1 week
no data

50
Appendix 9: Stone Free Rates for Medical Therapies by

Size
A special analysis of medical therapies was requested for stone sizes of <5, 5-10, and
>10 mm stones. Most studies didnt fit these ranges. Below is the analysis that was
possible.
Active therapies are listed. Most patients also received steroids, nsaids, and/or
antibiotics.
Medical Therapy
Article #
# Stone free
# pts
Notes
Nifedipine
9663
16332
16402
Meta-analysis:
31
24
13
74% (55 - 88)%
35
30
25
<10 mm
<15 mm
Tamsulosin or other alpha blockers as noted

14548
41
51
<10 mm
15156
30
30
18204
23
29
Tamsulosin
18204
22
28
Terazosin
18204
22
29
Doxazosin
18402
68
70
18522
8
15
<5 mm at 2 weeks
19764
24
32
for steinstrasse after SWL
Meta-analysis
all alpha blocker data
80% (70 - 87)%
excluding 19764
81% (70 - 89)%
tamsulosin only
82% (69 - 91)%
tamsulosin only excluding 19764
84% (69 - 93)%
Dual Arm Meta-analysis

8%
25%
27%
25%
27%
(-17 - 31)%
(16 - 33)%
(17 - 36)%
(16 - 33)%
(17 - 37)%
Nifedipine vs. control

all alpha blocker data vs. control
excluding 19764 vs. control
tamsulosin only vs. control
tamsulosin only excluding 19764 vs. control
Linked Meta-analysis
18% (-9 - 42)%
20% (-7 - 45)%
tamsulosin only vs. nifedipine

tamsulosin only excluding 19764 vs. nifedipine

51
Appendix 10: Complications Graphs

Death
Distal Ureter - SWL - all types

Distal Ureter - SWL - in situ
Distal Ureter <= 10 mm- SWL - all types
Distal Ureter <= 10 mm- SWL - in situ
Distal Ureter >= 10 mm- SWL - all types
Distal Ureter >= 10 mm- SWL - in situ
Mid Ureter - SWL - all types
Mid Ureter - SWL - in situ
Mid Ureter - URS - all types
Mid Ureter - URS - Flexible
Mid Ureter - URS - mixed flexible
Mid Ureter <= 10 mm- SWL - all types
Mid Ureter <= 10 mm- SWL - in situ
Mid Ureter >= 10 mm- SWL - all types
Mid Ureter >= 10 mm- SWL - in situ
Proximal Ureter - SWL - all types
Proximal Ureter - SWL - in situ
Proximal Ureter - URS - all types
Proximal Ureter - URS - Flexible
Proximal Ureter - URS - mixed flexible
Proximal Ureter <= 10 mm- SWL - all types
Proximal Ureter <= 10 mm- SWL - in situ
Proximal Ureter >= 10 mm- SWL - all types
Proximal Ureter >= 10 mm- SWL - in situ
0%
20%
40%
60%

CI, Confidence Interval

52
80%
100%
Transfusion

Distal Ureter - URS - all types
Distal Ureter - URS - mixed flexible


0%
20%
40%
60%


53
80%
100%
Cardiovascular/Pulmonary

Distal Ureter - URS - rigid

Proximal Ureter - SWL - other
0%
20%
40%
60%


54
80%
100%
Overall Significant Complications

Distal Ureter - SWL - other
Distal Ureter <= 10 mm- SWL - other
Distal Ureter <= 10 mm- URS - all types
Distal Ureter <= 10 mm- URS - rigid
Distal Ureter >= 10 mm- URS - all types
Distal Ureter >= 10 mm- URS - rigid
Mid Ureter - SWL - other
Mid Ureter - URS - rigid
Mid Ureter <= 10 mm- SWL - other
Mid Ureter <= 10 mm- URS - all types
Mid Ureter <= 10 mm- URS - rigid
Mid Ureter >= 10 mm- URS - all types
Mid Ureter >= 10 mm- URS - rigid
Proximal Ureter - URS - rigid
Proximal Ureter <= 10 mm- SWL - in situ
Proximal Ureter <= 10 mm- SWL - other
Proximal Ureter <= 10 mm- URS - all types
Proximal Ureter <= 10 mm- URS - mixed flexible
Proximal Ureter <= 10 mm- URS - rigid
Proximal Ureter >= 10 mm- URS - all types
Proximal Ureter >= 10 mm- URS - mixed flexible
Proximal Ureter >= 10 mm- URS - rigid
0%
20%
40%
60%


55
80%
100%
Sepsis
0%
20%
40%
60%


56
80%
100%
Steinstrasse
Distal Ureter - SWL - All types

Mid Ureter - SWL - All types

Proximal Ureter - SWL - All types

0%
20%
40%
60%


57
80%
100%
Ureteral Injury
Distal Ureter - SWL - All types
Distal Ureter >= 10 mm- URS - all types
Distal Ureter >= 10 mm- URS - rigid
Mid Ureter <= 10 mm- URS - all types
Mid Ureter <= 10 mm- URS - rigid
Mid Ureter >= 10 mm- URS - all types
Mid Ureter >= 10 mm- URS - rigid
Proximal Ureter - SWL - All types
0%
20%
40%


58
60%
80%
100%
Proximal Ureter - SWL - bypass
0%
20%
40%
60%


59
80%
100%
UTI


Proximal Ureter - SWL - bypass
0%
20%
40%
60%


60
80%
100%
Stricture
0%
20%
40%
60%


61
80%
100%
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Ureteral Calculi

EAU/AUA Nephrolithiasis Guideline Panel

2007 Guideline for the

Chapter 1: The Management of Ureteral Calculi: Diagnosis and

the management of symptomatic ureteral calculi. Other treatments were reviewed,

extraction process. An American and a European Panel member each independently

Evidence obtained from meta-analysis of randomized trials

Evidence obtained from at least one randomized trial

Evidence obtained from at least one well-designed controlled study

Evidence obtained from well-designed nonexperimental studies, such as

Evidence obtained from expert committee reports, or opinions, or clinical

Standard: A guideline statement is a standard if: (1) the health outcomes of

Recommendation: A guideline statement is a recommendation if: (1) the

Results of the Outcomes Analysis

Observation and Medical Therapies

Shock-wave Lithotripsy and Ureteroscopy

Stone Free Rates after Primary/First Treatment

Distal Ureter - SWL

Estimated Occurrence Rate with 95% CI

Table 2. Stone-Free Rates for SWL and URS, Pediatric Population

Figure 2. Stone-Free Rates for SWL and URS, Pediatric Population

Stone Free Rates after Primary/First Treatment

Distal Ureter - SWL

Estimated Occurrence Rate with 95% CI

Procedures per Patient

Distal Ureter - SWL

Weighted Mean Procedures per Patient

Procedures per Patient - Pediatric Patients

Distal Ureter - SWL

Weighted Mean Procedures per Patient

Table 6. Complication Occurrence Rates - Overall, Pediatric Population

G = number of groups/treatment arms extracted; P = number of patients in those groups.

Other Surgical Interventions

The Index Patient

Treatment Guidelines for the Index Patient

For Ureteral Stones <10 mm

option for initial treatment. Such patients may be offered an appropriate

For Ureteral Stones >10 mm

For Patients Requiring Stone Removal

no improved fragmentation with stenting.9 The current analysis demonstrates similar

in select cases with large impacted stones in the upper ureter

in combination with renal stone removal

in cases of ureteral stones after urinary diversion29

in select cases resulting from failure of retrograde ureteral access to large,

Option: Laparoscopic or open surgical stone removal may be considered in

Recommendations for the Pediatric Patient

Recommendations for the Nonindex Patient

Medical Expulsive Therapy

Percutaneous Antegrade Ureteroscopy

Laparoscopic and Open Stone Surgery

Uric acid Stones

Research and Future Directions

conducting RCTs comparing interventional techniques like URS and SWL

conducting pharmacological studies of stone-expulsion therapies as doubleblinded RCTs

reporting stone-free data without inclusion of residual fragments

using consistent nomenclature to report stone size, stone location, stone-free

reporting data stratified by patient/stone characteristics, such as patient age,

reporting all associated treatments including placement of ureteral stents or

using standardized methods to report acute and long-term outcomes

developing methods to predict outcomes for SWL, URS, and MET

providing measures of variability such as standard deviation, standard error,

reporting raw data to facilitate meta-analyses

The Panel suggests focusing on the following issues in future investigations: