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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

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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

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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

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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.
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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 5

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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
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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
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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 8

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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 9

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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. Ib. IIa. 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 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

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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.

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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

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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
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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.

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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]).

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Table 1. Stone-Free Rates for SWL and URS in the Overall Population

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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

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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.

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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.

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

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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 Distal Ureter < 10 mm - SWL Distal Ureter < 10 mm - URS Distal Ureter > 10 mm - SWL Mid Ureter - SWL Mid Ureter - URS Mid Ureter < 10 mm - SWL 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 - SWL 0% 20% 40% 60% 80% 100%

Estimated Occurrence Rate with 95% CI


CI=confidence interval

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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.

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Table 3. Procedure Counts for SWL and URS in the Overall Population

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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 - 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 0.0 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.

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Table 4. Procedure Counts for SWL and URS in the Pediatric Population, All Locations

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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 Distal Ureter < 10 mm - SWL Distal Ureter < 10 mm - URS Distal Ureter > 10 mm - SWL 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 0.0 0.5 1.0 1.5 2.0 2.5

Weighted Mean Procedures per Patient


Primary Procedures Secondary Procedures Adjunctive Procedures

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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.

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Table 5. Complications Occurrence Rates with SWL and URS, Overall Population
SWL Groups/Patients Med/95% CI Distal Ureter Sepsis 6 2019 1 26 2 609 1 45 3 87 2 398 1 37 1 43 3% (2 - 5)% 4% (0 - 17)% 0% (0 - 1)% 1% (0 - 5)% 4% (1 - 12)% 5% (0 - 20)% 8% (2 - 20)% 1% (0 - 6)% 7 326 10 514 1 37 5 704 3 235 2 124 2 124 5 360 6% (1 - 16)% 3% (2 - 4)% 5% (2 - 10)% 2% (0 - 8)% 2% (0 - 8)% 4% (2 - 7)% 1 63 8 360 1 109 8 987 10 1005 2 224 4% (2 - 7)% 6% (3 - 8)% 2% (0 - 7)% 4% (2 - 6)% 0% (0 - 2)% 2% (1 - 5)% 6% (3 - 9)% 4% (1 - 8)% 16 1911 23 4529 3 458 4 199 1% (1 - 2)% 3% (3 - 4)% 4% (2 - 7)% 4% (1 - 11)% URS Groups/Patients Med/95% CI 7 1954 2% (1 - 4)%

Steinstrasse

Stricture

Ureteral Injury

UTI Mid Ureter Sepsis

Steinstrasse

Stricture

Ureteral Injury

UTI Proximal Ureter Sepsis

Steinstrasse

Stricture

Ureteral Injury

UTI

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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.

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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.

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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. [Based on Panel consensus/Level IV] 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

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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

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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. [Based on Panel consensus/Level IV] 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. [Based on Panel consensus/Level IV] Standard: Patients should be followed with periodic imaging studies to monitor stone position and to assess for hydronephrosis. [Based on Panel consensus/Level IV] Standard: Stone removal is indicated in the presence of persistent obstruction, failure of stone progression, or in the presence of increasing or unremitting colic. [Based on Panel consensus/Level IV]

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.

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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. [Based on Panel consensus/Level IV] 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

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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. [Based on Panel consensus/Level III] 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

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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. [Based on Panel consensus/Level III] 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

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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. [Based on Panel consensus/Level III] 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

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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
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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

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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.

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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
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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
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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

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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
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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.

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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

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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
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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
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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
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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

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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

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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

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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
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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
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(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
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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.

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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.

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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.

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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
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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.
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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.

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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

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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

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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.
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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
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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-

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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

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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
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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.

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Table 1. Stone-Free Rates for Shock-wave Lithotripsy and Ureteroscopy in the Overall Population
Proximal Ureter
Shock-wave Lithotripsy
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 46/224 4/40 18/691 28/155 83% 83% 80% 81% 89% 87% 77% (79 - 87)% (72 - 91)% (72 - 86)% (77 - 85)% (75 - 97)% (82 - 91)% (71 - 83)%

G/P 14/886 1/67 5/578 1/59 7/182 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% 80% 84% 83% 77% (73 - 85)% (15 - 100)% (74 - 89)% (66 - 85)%

G/P 11/293 1/23 4/186 6/84 8/230 3/58 5/172

Size >10mm Media CI (2.5 - 97.5)% (55 - 79)% 68% (59 - 91)% 78% (59 - 92)% 78% 53% 79% 81% 81% (39 - 67)% (71 - 87)% (63 - 93)% (71 - 88)%

Ureteroscopy
All forms Flexible Mixed flexible Rigid

Mid Ureter
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other G/P 31/160 1/14 19/115 11/442 30/102 2/14 11/262 19/762

Primary/First Treatments Overall Median 73% 71% 77% 65% 86% 88% 88% 85% CI (2.5 - 97.5)% (66 - 79)% (45 - 89)% (69 - 84)% (51 - 77)% (81 - 89)% (53 - 99)% (79 - 94)% (79 - 89)% G/P 5/44 2/14 3/30 5/80 1/9 4/71

Size <10mm Median 84% 91% 77% 91% 87% 92% CI (2.5 - 97.5)% (65 - 95)% (67 - 99)% (47 - 95)% (81 - 96)% (59 - 99)% (82 - 97)% G/P 2/15 1/6 1/9 5/73 1/5 4/68

Size >10mm Median 76% 96% 66% 78% 60% 80% CI (2.5 97.5)% (36 - 97)% (67 - 100)% (35 - 90)% (61 - 90)% (21 - 91)% (66 - 90)%

Ureteroscopy
All forms Flexible Mixed flexible Rigid

Distal Ureter
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary/First Treatments Overall G/P Median CI (2.5 - 97.5)% 50/698 (73 - 75)%* 74% 42/649 8/486 59/595 1/2 9/431 50/552 75% 71% 94% 10% 93% 94% (73 - 75)%* (57 - 82)% (93 - 95)% (0 - 67)% (89 - 96)% (93 - 96)%

G/P 17/168 14/164 3/35 13/162 1/38 12/158

Size <10mm Median CI (2.5 - 97.5)% (80 - 91)% 86% 86% 90% 97% 97% 98% (79 - 92)% (75 - 98)% (96 - 98)% (88 - 100)% (96 - 99)%

G/P 10/966 9/965 1/1 8/412 1/10 7/402

Size >10mm CI (2.5 Median (57 - 87)% 74% 74% 84% 93% 79% 94% (56 - 88)% (15 - 100)% (88 - 96)% (50 - 96)% (90 - 97)%

Ureteroscopy
All forms Flexible Mixed flexible Rigid

Total Ureter
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary/First Treatments Size <10mm G/P 37/562 1/67 24/380 1/59 11/196 25/259 1/1 7/206 18/239 Median 86% 92% 85% 83% 88% 93% 84% 87% 95% CI (2.5 - 97.5)% (82 - 89)% (84 - 97)% (79 - 90)% (72 - 91)% (81 - 93)% (90 - 95)% (15 - 100)% (81 - 92)% (92 - 97)% G/P 27/2348 1/23 16/1627 10/698 19/928 5/94 14/834

Size >10mm Median 67% 78% 65% 70% 87% 81% 88% CI (2.5 97.5)% (59 - 75)% (59 - 91)% (53 - 76)% (57 - 82)% (83 - 90)% (67 - 92)% (85 - 91)%

Ureteroscopy
All forms Flexible Mixed flexible Rigid

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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
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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.

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Table 2. Stone-Free Rates for Shock-wave Lithotripsy and Ureteroscopy, Pediatric Population
Proximal Ureter
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other Primary/First Treatments Overall G/P Median CI (2.5 - 97.5)% 7/1 81% (69 - 90)% 4/6 3/3 5/1 1/3 4/1 85% 78% 57% 6% 67% (65 - 96)% (56 - 93)% (25 - 85)% (0 - 54)% (38 - 90)% Size <10mm Median CI (2.5 - 97.5)% 89% 99% 85% (72 - 98)% (88 - 100)% (59 - 97)% Size >10mm Median CI (2.5 - 97.5)% 63% 98% 36% (21 - 94)% (81 - 100)% (5 - 81)%

G/P 5/43 1/19 4/24

G/P 3/1 1/1 2/4

Ureteroscopy
All forms Flexible Mixed flexible Rigid

Mid Ureter
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other G/P 6/3 4/3 2/3 3/1

Primary/First Treatments Overall Median 82% 88% 56% 80% CI (2.5 - 97.5)% (63 - 94)% (70 - 97)% (8 - 96)% (52 0 96)% G/P 4/16 2/14 2/2

Size <10mm Median 80% 91% 50% CI (2.5 - 97.5)% (41 - 98)% (67 - 99)% (6 - 94)% 1/5 G/P 1/6 1/6

Size >10mm Median 96% 96% CI (2.5 - 97.5)% (67 - 100)% (67 - 100)%

Ureteroscopy
All forms Flexible Mixed flexible Rigid 78% (37 - 99)%

3/1

80%

(52 - 96)%

1/5

78%

(37 - 99)%

Distal Ureter
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary/First Treatments Overall G/P Median CI (2.5 - 97.5)% 8/2 80% (68 - 90)% 6/2 2/2 9/1 1/7 8/1 77% 95% 92% 84% 93% (63 - 87)% (79 - 100)% (86 - 96)% (50 - 98)% (87- 96)%

G/P 5/13 3/11 2/16 2/29

Size <10mm Median CI (2.5 - 97.5)% 86% (78 - 92)% 84% 93% 89% (68 - 94)% (72 - 100)% (72 - 98)%

G/P 2/2 1/2 1/1

Size >10mm Median CI (2.5 - 97.5)% 83% (58 - 97)% 87% 84% (71 - 97)% (15 - 100)%

Ureteroscopy
All forms Flexible Mixed flexible Rigid

2/29

89%

(72 - 98)%

Total Ureter
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary/First Treatments Size <10mm G/P Median CI (2.5 - 97.5)% 7/19 87% (80 - 93)% 3/15 4/47 3/72 86% 88% 91% (70 - 96)% (72 - 97)% (81 - 97)%

G/P 4/6 1/4 3/1 1/5

Size >10mm Median CI (2.5 - 97.5)% 73% (52 - 89)% 93% 55% 78% (83 - 98)% (26 - 81)% (37 - 98)%

Ureteroscopy
All forms Flexible Mixed flexible Rigid

3/72

91%

(81 - 97)%

1/5

78%

(37 - 98)%

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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.

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Table 3A. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Overall Population, Proximal Ureteral Stones
Stones All Sizes
Shock-wave Lithotripsy
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 42/1634 5/124 16/447 26/1187 Weighted Mean 1.02 1.00 1.03 1.02 Secondary Treatment Weighted G/P Mean 20/2131 0.07 8/416 12/1715 G/P 27/1831 6/197 21/1634 0.12 0.06 Weighted Mean 0.26 0.04 0.29 Adjunctive Treatment Weighted G/P Mean 0.24 13/1329 1.00 1/180 0.28 6/183 6/966 G/P 14/1159 4/104 7/451 7/708 0.09 Weighted Mean 0.17 1.00 0.25 0.13

Ureteroscopy
All forms Flexible Mixed flexible Rigid

Stones 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

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 9/277 3/36 6/241 Weighted Mean 1.02 1.00 1.02

Secondary Treatment Weighted G/P Mean 5/150 0.14 3/112 2/38 G/P 9/701 0.15 0.11 Weighted Mean 0.08

Adjunctive Treatment Weighted G/P Mean 0.77 3/114 1.00 1/67 0.45 2/47

Ureteroscopy
All forms Flexible Mixed flexible Rigid

G/P 5/119 2/18 3/101

Weighted Mean 0.64 0.28 0.70

9/701

0.08

Stones 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 1.49 11/510 2.00 1/23 1.52 4/424 6/63 G/P 5/137 2/30 3/107 1.14 Weighted Mean 1.07 1.00 1.09

Secondary Treatment Weighted G/P Mean 5/83 0.21 1/41 4/42 G/P 6/222 1/14 5/208 0.20 0.21 Weighted Mean 0.12 0.07 0.12

Adjunctive Treatment Weighted G/P Mean 0.56 4/45 1.00 1/23

3/22 G/P

0.09 Weighted Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid G/P, number of groups/number of patients.

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Table 3B. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Overall Population, Mid Ureteral Stones
Mid Ureter All Sizes
Shock-wave Lithotripsy
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 8/264 G/P 25/686 2/53 10/180 15/506 1.11 Weighted Mean 1.04 1.02 1.11 1.01 Secondary Treatment Weighted G/P Mean 9/316 0.18 3/71 6/245 G/P 15/934 2/66 13/868 0.06 0.21 Weighted Mean 0.07 0.21 0.06 Adjunctive Treatment Weighted G/P Mean 4/241 0.23 1/14 0.14 3/38 0.13 3/189 G/P 8/357 1/40 3/66 5/291 0.26 Weighted Mean 0.09 1.00 0.26 0.05

Ureteroscopy
All forms Flexible Mixed flexible Rigid

Mid Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 8/444 1.20 5/416 3/28 G/P 7/241 1/9 6/232 1.21 1.00 Weighted Mean 1.02 1.00 1.02

Secondary Treatment Weighted G/P Mean 2/80 0.15 2/80 0.15

Adjunctive Treatment Weighted G/P Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid

G/P 7/671

Weighted Mean 0.06

G/P 3/99

Weighted Mean 0.71

7/671

0.06

3/99

0.71

Mid Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 4/148 1.52 3/129 1/19 G/P 3/18 1/5 2/13 1.55 1.32 Weighted Mean 1.00 1.00 1.00

Secondary Treatment Weighted G/P Mean

Adjunctive Treatment Weighted G/P Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid G/P, number of groups/number of patients.

G/P 3/119

Weighted Mean 0.18

G/P 1/5

Weighted Mean 0.20

3/119

0.18

1/5

0.20

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Table 3C. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Overall Population, Distal Ureteral Stones
Distal Ureter All Sizes
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other Primary Treatment Weighted G/P Mean 48/7117 1.22 38/5963 10/1154 G/P 56/5308 1/2 7/277 49/5031 1.26 1.03 Weighted Mean 1.04 1.00 1.01 1.04 Secondary Treatment Weighted G/P Mean 30/5069 0.12 23/4297 7/772 G/P 25/5124 0.12 0.13 Weighted Mean 0.03 Adjunctive Treatment Weighted G/P Mean 15/3875 0.03 13/3500 2/375 G/P 24/2848 0.03 0.02 Weighted Mean 0.36

Ureteroscopy
All forms Flexible Mixed flexible Rigid

25/5124

0.03

24/2848

0.36

Distal Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 19/2031 1.31 14/1659 5/372 G/P 15/1326 1/38 14/1288 1.20 1.80 Weighted Mean 1.01 1.00 1.01

Secondary Treatment Weighted G/P Mean 7/250 0.13 7/250 0.13

Adjunctive Treatment Weighted G/P Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid

G/P 11/1131

Weighted Mean 0.05

G/P 6/397

Weighted Mean 0.83

11/1131

0.05

6/397

0.83

Distal Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 13/1065 1.43 11/1045 2/20 G/P 5/231 1/10 4/221 1.43 1.30 Weighted Mean 1.02 1.00 1.02

Secondary Treatment Weighted G/P Mean 3/1026 0.10 3/1026 0.10

Adjunctive Treatment Weighted G/P Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid G/P, number of groups/number of patients.

G/P 2/148

Weighted Mean 0.14

G/P 1/110

Weighted Mean 1.00

2/148

0.14

1/110

1.00

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Table 3D. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Overall Population, Total Ureteral Stones
Total Ureter 10 mm
Shock-wave Lithotripsy
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 17/1474 1/1 3/83 14/1391 Weighted Mean 1.02 1.00 1.00 1.02 Secondary Treatment Weighted G/P Mean 11/320 0.13 8/282 3/38 G/P 8/711 0.13 0.11 Weighted Mean 0.05 Adjunctive Treatment Weighted G/P Mean 6/152 0.61 1/67 1.00 2/47 0.45 3/38 G/P 7/381 1/1 2/18 5/363 0.11 Weighted Mean 0.78 1.00 0.28 0.81

Ureteroscopy
All forms Flexible Mixed flexible Rigid

8/711

0.05

Total Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 21/1860 1.49 1/23 2.00 14/1771 1.50 6/66 G/P 13/494 4/66 9/428 1.18 Weighted Mean 1.04 1.02 1.04

Secondary Treatment Weighted G/P Mean 9/1113 0.11 4/1067 5/46 G/P 6/234 1/14 5/220 0.10 0.28 Weighted Mean 0.08 0.07 0.08

Adjunctive Treatment Weighted G/P Mean 3/45 0.56 1/23 1.00

2/22 G/P 3/129 1/14 2/115

0.09 Weighted Mean 0.89 0.21 0.97

Ureteroscopy
All forms Flexible Mixed flexible Rigid

G/P, number of groups/number of patients.

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.

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Table 4A. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Pediatric Population, Proximal Ureteral Stones
Proximal Ureter All Sizes
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other 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 Adjunctive Treatment Weighted G/P Mean 1/5 0.00

2/34 G/P 6/27 1/3 5/24

1.12 Weighted Mean 1.00 1.00 1.00

2/25 G/P 7/38 2/6 5/32

0.04 Weighted Mean 0.34 0.50 0.31

1/5 G/P 1/9

0.00 Weighted Mean 1.00

Ureteroscopy
All forms Flexible Mixed flexible Rigid

1/9

1.00

Proximal Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 6/69 1.12 1/19 5/50 G/P 2/55 1.42 1.00 Weighted Mean 1.07

Secondary Treatment Weighted G/P Mean 1/3 0.00

Adjunctive Treatment Weighted G/P Mean 1/3 0.00

1/3 G/P 5/156

0.00 Weighted Mean 0.12

1/3 G/P 3/101

0.00 Weighted Mean 0.70

Ureteroscopy
All forms Flexible Mixed flexible Rigid

2/55

1.07

5/156

0.12

3/101

0.70

Proximal Ureter10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 4/16 1.38 1/12 3/4 G/P 1.50 1.00 Weighted Mean

Secondary Treatment Weighted G/P Mean 2/2 0.00

Adjunctive Treatment Weighted G/P Mean 2/2 0.00

2/2 G/P

0.00 Weighted Mean

2/2 G/P

0.00 Weighted Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid G/P, number of groups/number of patients.

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Table 4B. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Pediatric Population, Mid Ureteral Stones
Mid Ureter All Sizes
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other Primary Treatment Weighted G/P Mean 4/32 1.44 3/29 1/3 G/P 4/18 1.48 1.00 Weighted Mean 1.00 Secondary Treatment Weighted G/P Mean 1/9 0.11 1/9 0.11 Adjunctive Treatment Weighted G/P Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid

G/P 2/12

Weighted Mean 0.17

G/P 2/12

Weighted Mean 0.75

4/18

1.00

2/12

0.17

2/12

0.75

Mid Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 5/42 0.67 2/14 3/28 G/P 2/53 0.02 1.00 Weighted Mean 1.08

Secondary Treatment Weighted G/P Mean

Adjunctive Treatment Weighted G/P Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid

G/P 4/145

Weighted Mean 0.09

G/P 3/99

Weighted Mean 0.71

2/53

1.08

4/145

0.09

3/99

0.71

Mid Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 1/6 1.33 1/6 1.33

Secondary Treatment Weighted G/P Mean

Adjunctive Treatment Weighted G/P Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid G/P, number of groups/number of patients.

G/P 1/5

Weighted Mean 1.00

G/P 1/5

Weighted Mean 0.20

G/P 1/5

Weighted Mean 0.20

1/5

1.00

1/5

0.20

1/5

0.20

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Table 4C. Procedure Counts for Shock-wave Lithotripsy and Ureteroscopy in the Pediatric Population, Distal Ureteral Stones
Distal Ureter All Sizes
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other Primary Treatment Weighted G/P Mean 7/212 1.38 6/188 1/24 G/P 10/185 2/24 8/161 1.43 1.00 Weighted Mean 1.05 1.00 1.06 Secondary Treatment Weighted G/P Mean 4/98 0.08 4/98 0.08 Adjunctive Treatment Weighted G/P Mean 2/43 0.07 2/43 0.07

Ureteroscopy
All forms Flexible Mixed flexible Rigid

G/P 7/190 1/17 6/173

Weighted Mean 0.09 0.06 0.09

G/P 5/96 1/17 4/79

Weighted Mean 0.72 0.12 0.85

Distal Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 6/161 1.35 3/119 3/42 G/P 4/109 1/17 3/92 1.48 1.00 Weighted Mean 1.03 1.00 1.04

Secondary Treatment Weighted G/P Mean 1/14 0.36 1/14 0.36

Adjunctive Treatment Weighted G/P Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid

G/P 8/269 1/17 7/252

Weighted Mean 0.10 0.06 0.10

G/P 4/143 1/17 3/126

Weighted Mean 0.71 0.12 0.79

Distal Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 4/26 1.42 3/25 1/1 G/P 1.44 1.00 Weighted Mean

Secondary Treatment Weighted G/P Mean

Adjunctive Treatment Weighted G/P Mean

Ureteroscopy
All forms Flexible Mixed flexible Rigid G/P, number of groups/number of patients.

G/P

Weighted Mean

G/P

Weighted Mean

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

Ureteroscopy
All forms Flexible Mixed flexible Rigid

Total Ureter 10 mm
Shock-wave Lithotripsy
All forms Bypass In situ Pushback Other

Primary Treatment Weighted G/P Mean 3/48 1.39 1//43 2/5 G/P 1/5 1.44 1.00 Weighted Mean 1.00

Secondary Treatment Weighted G/P Mean 1/2 0.00

Adjunctive Treatment Weighted G/P Mean 1/2 0.00

1/2 G/P 1/5

Ureteroscopy
All forms Flexible Mixed flexible Rigid G/P, number of groups/number of patients.

0.00 Weighted Mean 0.20

1/2 G/P 1/5

0% Weighted Mean 0.20

1/5

1.00

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
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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
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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.

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Table 5. Complication Occurrence Rates with Shock-Wave Lithotripsy (SWL) and Ureteroscopy (URS) by Treatment, Size, and Location in the Overall Population
Complication Category Cardiovascular Stone Location Distal Ureter Size Treatment SWL - all types SWL - in situ URS - all types URS - rigid SWL - all types SWL - other URS - all types URS - mixed flexible SWL - all types SWL - in situ 10 mm SWL - all types SWL - in situ SWL - all types SWL - in situ SWL - all types SWL - in situ URS - all types URS - flexible URS - mixed flexible 10 mm SWL - all types SWL - in situ SWL - all types SWL - in situ No. of Groups 1 1 1 1 1 1 1 1 2 2 1 1 1 1 2 2 1 1 1 1 1 1 1 No. of Pts 395 395 32 32 111 111 109 109 1,185 1,185 341 341 105 105 238 238 40 40 40 44 44 30 30 Med. Prob. 2% 2% 4% 4% 0% 0% 2% 2% 0% 0% 0% 0% 0% 0% 0% 0% 1% 1% 1% 1% 1% 1% 1% 95% CI (1 - 3)% (1 - 3)% (0 - 14)% (0 - 14)% (0 - 2)% (0 - 2)% (0 - 6)% (0 - 6)% (0 - 1)% (0 - 0)% (0 - 1)% (0 - 1)% (0 - 2)% (0 - 2)% (0 - 1)% (0 - 1)% (0 - 6)% (0 - 6)% (0 - 6)% (0 - 6)% (0 - 6)% (0 - 8)% (0 - 8)%

Proximal Ureter

Death

Distal Ureter

Distal Ureter

Distal Ureter

10 mm

Mid Ureter

Mid Ureter

Mid Ureter

10 mm

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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 Proximal Ureter Size Treatment SWL - all types SWL - in situ URS - all types URS - flexible URS - mixed flexible 10 mm SWL - all types SWL - in situ SWL - all types SWL - in situ SWL - all types SWL - in situ SWL - other URS - all types URS - mixed flexible URS - rigid 10 mm SWL - all types SWL - in situ SWL - other URS - all types URS - rigid SWL - all types SWL - in situ URS - all types URS - rigid No. of Groups 2 2 1 1 1 1 1 1 1 11 9 2 18 3 15 4 3 1 6 6 2 2 3 3 No. of Pts 1,143 1,143 84 84 84 151 151 117 117 2,027 1,974 53 1,902 132 1,770 809 800 9 532 532 197 197 177 177 Med. Prob. 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% Distal Ureter 1% 3% 7% 9% 7% 1% 0% 2% 6% 6% 1% 1% 16% 16% (0 - 2)% (0 - 1)% (0 - 11)% (5 - 10)% (4 - 16)% (4 - 10)% (0 - 2)% (0 - 1)% (0 - 24)% (3 - 12)% (3 - 12)% (0 - 3)% (0 - 3)% (5 - 35)% (5 - 35)% 95% CI (0 - 0)% (0 - 0)% (0 - 3)% (0 - 3)% (0 - 3)% (0 - 2)% (0 - 2)% (0 - 2)% (0 - 2)%

Proximal Ureter

Proximal Ureter

10 mm

Overall Significant

Distal Ureter

Distal Ureter

10 mm

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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 Mid Ureter Size Treatment SWL - all types SWL - in situ SWL - other URS - all types URS - flexible URS - mixed flexible URS - rigid SWL - all types SWL - in situ SWL - other URS - all types URS - rigid URS - all types URS - rigid SWL - all types SWL - in situ SWL - other URS - all types URS - flexible URS - mixed flexible URS - rigid 10 mm SWL - all types SWL - in situ SWL - other URS - all types URS - mixed flexible URS - rigid No. of Groups 4 2 2 9 1 3 6 2 1 1 1 1 1 1 6 3 3 13 1 5 8 2 1 1 3 2 1 No. of Pts 149 125 24 126 1 27 99 91 90 1 15 15 8 8 622 453 169 383 8 190 193 165 151 14 120 98 22 Med. Prob. 3% 1% 8% 14% 16% 13% 15% 1% 0% 16% 14% 14% 14% 14% 4% 1% 11% 11% 3% 12% 10% 1% 0% 2% 12% 15% 1% 95% CI (0 - 9)% (0 - 6)% (0 - 34)% (8 - 22)% (0 - 85)% (2 - 34)% (8 - 24)% (0 - 7)% (0 - 3)% (0 - 85)% (3 - 36)% (3 - 36)% (1 - 45)% (1 - 45)% (1 - 12)% (0 - 5)% (2 - 34)% (6 - 17)% (0 - 26)% (4 - 26)% (6 - 17)% (0 - 7)% (0 - 2)% (0 - 16)% (2 - 32)% (1 - 47)% (0 - 11)%

Mid Ureter

10 mm

Mid Ureter

10 mm

Overall Significant

Proximal Ureter

Proximal Ureter

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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 Proximal Ureter Size 10 mm Treatment SWL - all types SWL - in situ URS - all types URS - mixed flexible URS - rigid No. of Groups 1 1 4 2 2 No. of Pts 117 117 108 42 66 Med. Prob. 0% 0% 17% 24% 10% 95% CI (0 - 2)% (0 - 2)% (6 - 34)% (2 - 69)% (3 - 21)%

Sepsis

Distal Ureter

SWL - all types SWL - in situ SWL - other URS - all types URS - mixed flexible URS - rigid 10 mm SWL - all types SWL - in situ SWL - other URS - all types URS - rigid SWL - all types SWL - in situ SWL - all types SWL - in situ SWL - other URS - all types URS - flexible URS - mixed flexible

6 5 1 7 1 6 2 1 1 1 1 1 1 2 1 1 4 1 2

2,019 2,003 16 1,954 109 1,845 53 44 9 12 12 342 342 398 396 2 199 40 43

3% 3% 1% 2% 0% 2% 4% 3% 2% 2% 2% 4% 4% 5% 2% 10% 4% 1% 5%

(2 - 5)% (2 - 5)% (0 - 14)% (1 - 4)% (0 - 2)% (1 - 4)% (1 - 14)% (0 - 10)% (0 - 24)% (0 - 19)% (0 - 19)% (2 - 6)% (2 - 6)% (0 - 20)% (1 - 4)% (0 - 67)% (1 - 11)% (0 - 6)% (0 - 24)%

Distal Ureter

Distal Ureter

10 mm

Mid Ureter

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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 Size Treatment URS - rigid SWL - all types SWL - other SWL - all types SWL - in situ SWL - other URS - all types URS - flexible URS - mixed flexible URS - rigid 10 mm SWL - all types SWL - other SWL - all types SWL - in situ URS - all types URS - rigid No. of Groups 2 1 1 5 2 3 8 1 4 4 1 1 1 1 1 1 No. of Pts 156 1 1 704 499 205 360 84 213 147 14 14 41 41 41 41 Med. Prob. 3% 16% 16% 3% 3% 2% 4% 0% 3% 5% 2% 2% 1% 1% 1% 1% 95% CI (0 - 14)% (0 - 85)% (0 - 85)% (2 - 4)% (2 - 5)% (1 - 6)% (2 - 6)% (0 - 3)% (1 - 7)% (2 - 10)% (0 - 16)% (0 - 16)% (0 - 6)% (0 - 6)% (0 - 6)% (0 - 6)%

Mid Ureter

10 mm

Sepsis

Proximal Ureter

Proximal Ureter

Proximal Ureter

10 mm

Steinstrasse

Distal Ureter

SWL - all types SWL - other SWL - all types SWL - other SWL - all types SWL - in situ

1 1 1 1 3 1

26 26 37 37 235 50

4% 4% 8% 8% 5% 6%

(0 - 17)% (0 - 17)% (2 - 20)% (2 - 20)% (2 - 10)% (2 - 15)%

Mid Ureter

Proximal Ureter Copyright 2007 American Urological Association Education and Research, Inc. and European Association of Urology

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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 Size Treatment SWL - other URS - all types URS - mixed flexible 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)%

Stricture

Distal Ureter

SWL - all types SWL - in situ URS - all types URS - mixed flexible URS - rigid 10 mm SWL - all types SWL - in situ URS - all types URS - rigid SWL - all types SWL - in situ SWL - all types SWL - in situ URS - all types URS - flexible URS - mixed flexible URS - rigid 10 mm SWL - all types SWL - in situ SWL - all types

2 2 16 2 14 1 1 2 2 1 1 1 1 7 1 4 3 1 1 1

609 609 1,911 76 1,835 28 28 125 125 63 63 43 43 326 1 43 283 15 15 24

0% 0% 1% 4% 1% 1% 1% 2% 2% 0% 0% 1% 1% 4% 16% 8% 2% 1% 1% 1%

(0 - 1)% (0 - 1)% (1 - 2)% (1 - 14)% (1 - 2)% (0 - 9)% (0 - 9)% (0 - 9)% (0 - 9)% (0 - 4)% (0 - 4)% (0 - 6)% (0 - 6)% (2 - 7)% (0 - 85)% (2 - 22)% (1 - 6)% (0 - 15)% (0 - 15)% (0 - 10)%

Distal Ureter

Distal Ureter

10 mm

Mid Ureter

Mid Ureter

Mid Ureter

10 mm

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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 Size Treatment SWL - in situ SWL - all types SWL - in situ SWL - other URS - all types URS - flexible URS - mixed flexible URS - rigid 10 mm URS - all types URS - rigid URS - all types URS - rigid No. of Groups 1 2 1 1 8 1 4 4 1 1 1 1 No. of Pts 24 124 13 111 987 8 164 823 64 64 51 51 Med. Prob. 1% 2% 2% 0% 2% 3% 3% 2% 0% 0% 0% 0% 95% CI (0 - 10)% (0 - 8)% (0 - 17)% (0 - 2)% (1 - 5)% (0 - 26)% (1 - 8)% (0 - 5)% (0 - 4)% (0 - 4)% (0 - 5)% (0 - 5)%

Proximal Ureter

Proximal Ureter

Proximal Ureter

10 mm

Transfusion

Distal Ureter

SWL - all types SWL - in situ URS - all types URS - mixed flexible 10 mm SWL - all types SWL - in situ SWL - all types SWL - in situ SWL - all types SWL - in situ

1 1 1 1 1 1 1 1 1 1

91 91 109 109 28 28 63 63 43 43

0% 0% 0% 0% 1% 1% 0% 0% 1% 1%

(0 - 3)% (0 - 3)% (0 - 2)% (0 - 2)% (0 - 9)% (0 - 9)% (0 - 4)% (0 - 4)% (0 - 6)% (0 - 6)%

Distal Ureter

Distal Ureter

10 mm

Mid Ureter Copyright 2007 American Urological Association Education and Research, Inc. and European Association of Urology

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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 Mid Ureter Size 10 mm Treatment SWL - all types SWL - in situ SWL - all types SWL - in situ URS - all types URS - mixed flexible No. of Groups 1 1 1 1 1 1 No. of Pts 15 15 28 28 17 17 Med. Prob. 1% 1% 1% 1% 1% 1% 95% CI (0 - 15)% (0 - 15)% (0 - 9)% (0 - 9)% (0 - 14)% (0 - 14)%

Mid Ureter

10 mm

Proximal Ureter

Ureteral Injury

Distal Ureter

SWL - All types SWL - in situ URS - all types URS - mixed flexible URS - rigid 10 mm URS - all types URS - rigid URS - all types URS - rigid URS - all types URS - flexible URS - mixed flexible URS - rigid 10 mm URS - all types URS - rigid

1 1 23 4 19 3 3 1 1 10 1 4 6 2 2

45 45 4,529 298 4,231 215 215 71 71 514 40 91 423 31 31

1% 1% 3% 5% 3% 2% 2% 0% 0% 6% 1% 5% 6% 8% 8%

(0 - 5)% (0 - 5)% (3 - 4)% (3 - 8)% (2 - 4)% (0 - 5)% (0 - 5)% (0 - 3)% (0 - 3)% (3 - 8)% (0 - 6)% (1 - 13)% (3 - 9)% (0 - 39)% (0 - 39)%

Distal Ureter

Distal Ureter

10 mm

Mid Ureter

Mid Ureter

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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 Mid Ureter Size 10 mm Treatment URS - all types URS - rigid SWL - all types SWL - in situ SWL - other URS - all types URS - flexible URS - mixed flexible URS - rigid 10 mm URS - all types URS - rigid URS - all types URS - rigid No. of Groups 1 1 2 1 1 10 1 3 7 3 3 2 2 No. of Pts 33 33 124 13 111 1,005 84 200 805 74 74 92 92 Med. Prob. 1% 1% 2% 2% 0% 6% 0% 2% 7% 9% 9% 1% 1% 95% CI (0 - 7)% (0 - 7)% (0 - 8)% (0 - 17)% (0 - 2)% (3 - 9)% (0 - 3)% (0 - 6)% (4 - 12)% (1 - 28)% (1 - 28)% (0 - 6)% (0 - 6)%

Proximal Ureter

Proximal Ureter

Proximal Ureter

10 mm

Ureteral Obstruction

Distal Ureter

SWL - All types SWL - in situ SWL - other URS - all types URS - rigid 10 mm SWL - all types SWL - in situ SWL - other SWL - all types SWL - in situ

5 4 1 2 2 4 3 1 1 1

330 314 16 185 185 95 86 9 63 63

3% 2% 1% 2% 2% 5% 4% 2% 0% 0%

(1 - 6)% (1 - 6)% (0 - 14)% (1 - 6)% (1 - 6)% (1 - 11)% (1 - 12)% (0 - 24)% (0 - 4)% (0 - 4)%

Distal Ureter

Distal Ureter

10 mm

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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 Mid Ureter Size Treatment SWL - all types SWL - in situ SWL - other URS - all types URS - mixed flexible 10 mm SWL - all types SWL - in situ SWL - other SWL - all types SWL - in situ SWL - all types SWL - bypass SWL - in situ SWL - other 10 mm SWL - all types SWL - other No. of Groups 3 2 1 1 1 2 1 1 1 1 4 1 2 1 1 1 No. of Pts 64 62 2 25 25 16 15 1 28 28 430 90 320 20 14 14 Med. Prob. 9% 6% 10% 1% 1% 11% 1% 16% 1% 1% 2% 2% 2% 1% 2% 2% 95% CI (1 - 24)% (0 - 25)% (0 - 67)% (0 - 9)% (0 - 9)% (0 - 46)% (0 - 15)% (0 - 85)% (0 - 9)% (0 - 9)% (1 - 4)% (0 - 7)% (0 - 6)% (0 - 12)% (0 - 16)% (0 - 16)%

Mid Ureter

Mid Ureter

10 mm

Proximal Ureter

Proximal Ureter

Urinary Tract Infection

Distal Ureter

SWL - all types SWL - in situ SWL - other URS - all types URS - rigid 10 mm SWL - all types SWL - other

3 1 2 3 3 1 1

87 45 42 458 458 9 9

4% 5% 3% 4% 4% 2% 2%

(1 - 12)% (1 - 14)% (0 - 13)% (2 - 7)% (2 - 7)% (0 - 24)% (0 - 24)%

Distal Ureter

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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 Size Treatment URS - all types URS - rigid SWL - all types SWL - other URS - all types URS - rigid 10 mm SWL - all types SWL - other SWL - all types SWL - bypass SWL - in situ SWL - other URS - all types URS - mixed flexible URS - rigid 10 mm SWL - all types SWL - other No. of Groups 1 1 1 1 1 1 1 1 5 1 1 3 2 1 1 1 1 No. of Pts 12 12 37 37 63 63 1 1 360 90 65 205 224 109 115 14 14 Med. Prob. 2% 2% 6% 6% 2% 2% 16% 16% 4% 1% 8% 4% 4% 4% 3% 2% 2% 95% CI (0 - 19)% (0 - 19)% (1 - 16)% (1 - 16)% (0 - 7)% (0 - 7)% (0 - 85)% (0 - 85)% (2 - 7)% (0 - 5)% (3 - 16)% (1 - 8)% (1 - 8)% (1 - 8)% (1 - 7)% (0 - 16)% (0 - 16)%

Mid Ureter

Mid Ureter

Proximal Ureter

Proximal Ureter

No., number; Prob., probability; SWL, shock-wave lithotripsy; URS, ureteroscopy

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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
G/P Bleeding Overall Significant Complications Pain Retention Sepsis Skin Stricture Ureteral Obstruction Urinary Tract Infection 2/206 1/38 3/106 1/63 2/101 1/168 1/25 4/283 2/63 Median 5% 1% 18% 2% 4% 0% 1% 2% 2% CI (2.5 - 97.5)% (0 - 24)% (0 - 6)% (9 - 30)% (0 - 7)% (1 - 12)% (0 - 1)% (0 - 9)% (1 - 6)% (0 - 9)% CI (2.5 - 97.5)% (9 - 27)% (2 - 13)% (1 - 14)% (1 - 13)% (0 - 17)% (0 - 9)% (0 - 17)% (3 - 10)% (0 - 9)% (0 - 19)% (2 - 11)% (5 - 24)% 1/25 1/29 5% 4% (0 - 17)% (0 - 15)% 5/187 1/26 1/12 5/106 1/43 6% 1% 2% 5% 12% (2 - 11)% (0 - 9)% (0 - 19)% (2 - 11)% (5 - 24)% 3/106 1/63 1/63 1/168 1/25 3/245 1/25 18% 2% 5% 0% 1% 3% 1% (9 - 30)% (0 - 7)% (1 - 12)% (0 - 1)% (0 - 9)% (1 - 6)% (0 - 9)% CI (2.5 - 97.5)% (0 - 17)% (1 - 41)% 1/38 1/38 1% 1% (0 - 6)% (0 - 6)% CI (2.5 - 97.5)% (9 - 27)% (1 - 12)% (0 - 13)% (1 - 13)% (0 - 17)% (0 - 9)% 1/38 1% (0 - 6)% G/P 2/206

SWL in Situ
Median 5% CI (2.5 - 97.5)% (0 - 24)% G/P

SWL - Other
Median CI (2.5 - 97.5)% (0 - 6)%

1/38

1%

URS Overall
G/P Bleeding Infection Overall Significant Complications Pain Retention Sepsis Stent Migration Ureteral Injury Ureteral Obstruction Urinary Tract Infection Stricture Other Long -term complications 1/66 2/91 5/65 3/98 1/26 3/73 1/25 6/216 1/26 1/12 5/106 1/43 Median 17% 6% 5% 5% 4% 3% 5% 6% 1% 2% 5% 12% G/P 1/25 2/10

URS Mixed Flexible


Median G/P 1/66 5% 11% 1/66 3/55 3/98 1/26 3/73

URS Rigid/Semi-rigid
Median 17% 5% 4% 5% 4% 3%

CI, confidence interval

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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.

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Table 7. Stone-Free Rates for Other Surgical Interventions in the Overall Population
Proximal Ureter
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery Primary/First Treatments Overall G/P Median CI (2.5 - 9.5)% 5/91 84% (75 - 91)% 4/176 95% (90 - 98)% Size <10mm Median CI (2.5 - 9.5)% 84% (15 - 100)% Size >10mm Median CI (2.5 - 9.5)% 81% (54 - 96)% 97% (92 - 100)%

G/P 1/1

G/P 3/13 2/89

Mid Ureter
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

Primary/First Treatments Overall G/P 1/10 Median 98% CI (2.5 97.5)% (78 - 100)% G/P

Size <10mm Median CI (2.5 - 9.5)% G/P

Size >10mm Median CI (2.5 - 9.5)%

Distal Ureter
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

Primary/First Treatments Overall G/P 1/15 1/122 Median 86% 97% CI (2.5 - 9.5)% (64 - 97)% (92 - 99)% G/P

Size <10mm Median CI (2.5 - 9.5)% G/P

Size >10mm Median CI (2.5 - 9.5)%

Total Ureter
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

Primary/First Treatments Overall G/P Median CI (2.5 - 9.5)% G/P 2/7

Size <10mm Median 76% CI (2.5 - 9.5)% (38 - 96)% G/P 5/37 2/89

Size >10mm Median 85% 97% CI (2.5 - 9.5)% (68 - 95)% (92 - 100)%

G/P, number of groups/number of patients; PNL, percutaneous antegrade ureteroscopy.

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Table 8A. Procedure Counts for Other Surgical Interventions in the Overall Population, Proximal Ureteral Stones
Proximal Ureter All Sizes
Other Surgeries
Laparoscopic Stone Removal 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 Adjunctive Treatment Weighted G/P Mean 1/2 1.00 5/242 0.73

Proximal Ureter 10 mm
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

Primary Treatment Weighted G/P Mean 2/7 1.00

Secondary Treatment Weighted G/P Mean 1/6 0.17

Adjunctive Treatment Weighted G/P Mean 2/7 1.00

Proximal Ureter 10 mm
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

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

Adjunctive Treatment Weighted G/P Mean 2/7 1.00 3/155 0.58

G/P, number of groups/number of patients; PNL, percutaneous antegrade ureteroscopy.

Table 8B. Procedure Counts for Other Surgical Interventions in the Overall Population, Mid Ureteral Stones
Mid Ureter All Sizes
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery Primary Treatment Weighted G/P Mean Secondary Treatment Weighted G/P Mean Adjunctive Treatment Weighted G/P Mean

Mid Ureter 10 mm
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

Primary Treatment Weighted G/P Mean 1/6 1.00

Secondary Treatment Weighted G/P Mean 1/6 0.17

Adjunctive Treatment Weighted G/P Mean 1/6 1.00

Mid Ureter 10 mm
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

Primary Treatment Weighted G/P Mean 1/6 1.00

Secondary Treatment Weighted G/P Mean 1/6 0.17

Adjunctive Treatment Weighted G/P Mean 1/6 1.00

G/P, number of groups/number of patients; PNL, percutaneous antegrade ureteroscopy.

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Table 8C. Procedure Counts for Other Surgical Interventions in the Overall Population, Distal Ureteral Stones
Distal Ureter All Sizes
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery Primary Treatment Weighted G/P Mean 1/15 1.00 1/122 1.00 Secondary Treatment Weighted G/P Mean 1/6 0.17 Adjunctive Treatment Weighted G/P Mean 1/6 1.00 Secondary Treatment Weighted G/P Mean 1/15 0.13 Adjunctive Treatment Weighted G/P Mean

Distal Ureter 10 mm
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

Primary Treatment Weighted G/P Mean 1/6 1.00

Distal Ureter 10 mm
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

Primary Treatment Weighted G/P Mean 1/6 1.00

Secondary Treatment Weighted G/P Mean 1/6 0.17

Adjunctive Treatment Weighted G/P Mean 1/61 1.00

G/P, number of groups/number of patients; PNL, percutaneous antegrade ureteroscopy.

Table 8D. Procedure Counts for Other Surgical Interventions in the Overall Population, Total Ureteral Stones
Total Ureter 10 mm
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery Primary Treatment Weighted G/P Mean 2/7 1.00 Secondary Treatment Weighted G/P Mean 1/6 0.17 Adjunctive Treatment Weighted G/P Mean 2/7 1.00

Total Ureter 10 mm
Other Surgeries
Laparoscopic Stone Removal PNL Open Surgery

Primary Treatment G/P 5/37 1/89 1/18 Weighted Mean 1.00 1.00 1.00

Secondary Treatment G/P 2/12 1/66 Weighted Mean 0.17 0.02

Adjunctive Treatment G/P 4/43 3/155 Weighted Mean 0.30 0.58

G/P, number of groups/number of patients; PNL, percutaneous antegrade ureteroscopy.

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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%).

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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

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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.

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2007 Guideline for the Management of Ureteral Calculi

Appendixes

European Association of Urology American Urological Association Education and Research, Inc.

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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

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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 Department of Urology 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

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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: Hanan S. Bell, Ph.D. (Consultant in Methodology) Seattle, Washington Patrick M. Florer (Database Design and Coordination) Dallas, Texas Curtis Colby (Editor) Washington, D.C.

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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)

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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 Department of Urology Wake Forest University School of Medicine Winston-Salem, North Carolina Peter Alken, M.D., Ph.D. Department of Urology 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. Department of Urology Klinikum Mannheim Medizinische Fakultt Mannheim der Universitt Heidelberg Mannheim, Germany

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James E. Lingeman, M.D. Department of Urology 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. Department of Urology University of Texas Southwestern Medical Center Dallas, Texas Kemal Sarica, M.D., Ph.D. Department of Urology Memorial Hospital Istanbul, Turkey Christian Trk, M.D., Ph.D. Urology Department Rudolfspital Vienna, Austria J. Stuart Wolf, Jr., M.D. Department of Urology University of Michigan Ann Arbor, MI Consultants: Hanan S. Bell, Ph.D. Patrick M. Florer Diann Glickman, PharmD

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Appendix 4: Article Status Report

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Appendix 5: Article Extraction Form


(continued on next page)

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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 Aghamir, S. K., Mohseni, M. G., Ardestani, A. Treatment of ureteral calculi with ballistic lithotripsy. Journal of Endourology. 2003; 17: 887-90 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 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 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 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 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 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 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 Anagnostou, T., Tolley, D. Management of ureteric stones. [Review] [64 refs] European Urology. 2004; 45: 714-21 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. 2001; 15: 493-8 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 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 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 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

15606

17128

19854

7686

8030

18958

16046

6472

16616

10696

15872

18154

14430

9598

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Deliveliotis, C., Giannakopoulos, S., Louras, G., Koutsokalis, G., Alivizatos, G., Kostakopoulos, A. Double-pigtail stents for distal ureteral calculi: an alternative form of definitive treatment Urologia Internationalis. 1996; 57: 224-226 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. 1996; 56: 21-22 Deliveliotis, C., Stavropoulos, N.I., Koutsokalis, G., Kostakopoulos, A., Dimopoulos, C. Distal ureteral calculi: ureteroscopy vs. ESWL. A prospective analysis International Urology & Nephrology. 1996; 28: 627-631 Dellabella, M., Milanese, G., Muzzonigro, G. Efficacy of tamsulosin in the medical management of juxtavesical ureteral stones. Journal of Urology. 2003; 170: 2202-5 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. 2005; 174: 167-72 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. 2003; 61: 518-522 Delvecchio, F.C., Kuo, R.L., Preminger, G.M. Clinical efficacy of combined lithoclast and lithovac stone removal during ureteroscopy Journal of Urology. 2000; 164: 40-42 Demirbas, M., Kose, A. C., Samli, M., Guler, C., Kara, T., Karalar, M. Extracorporeal shockwave lithotripsy for solitary distal ureteral stones: does the degree of urinary obstruction affect success?. Journal of Endourology. 2004; 18: 237-40 Demirci, D., Gulmez, I., Ekmekcioglu, O., Karacagil, M. Retroperitoneoscopic ureterolithotomy for the treatment of ureteral calculi. Urologia Internationalis. 2004; 73: 234-7 Denstedt, J.D., Chun, S.S., Miller, M.D., Eberwein, P.M. Intracorporeal lithotripsy with the Alexandrite laser Lasers In Surgery & Medicine. 1997; 20: 433-436 Denstedt, J.D., Wollin, T.A., Sofer, M., Nott, L., Weir, M., D'A Honey, R.J. A prospective randomized controlled trial comparing nonstented versus stented ureteroscopic lithotripsy Journal of Urology. 2001; 165: 1419-1422 Desai, M. R., Patel, S. B., Desai, M. M., Kukreja, R., Sabnis, R. B., Desai, R. M., Patel, S. H. The Dretler stone cone: a device to prevent ureteral stone migration-the initial clinical experience. Journal of Urology. 2002; 167: 1985-8 Devarajan, R., Ashraf, M., Beck, R.O., Lemberger, R.J., Taylor, M.C. Holmium: YAG lasertripsy for ureteric calculi: an experience of 300 procedures British Journal of Urology. 1998; 82: 342-347 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.. 2004; 72: 48-5 Dogan, H. S., Tekgul, S., Akdogan, B., Keskin, M. S., Sahin, A. Use of the holmium:yag laser for ureterolithotripsy in children. BJU International. 2004; 94: 131-3 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 & Nephrology. 1997; 31: 137-139 Dretler, S.P. Ureteroscopy for proximal ureteral calculi: prevention of stone migration Journal of Endourology. 2000; 14: 565-567 du Fosse, W., Billiet, I., Mattelaer, J. Ureteroscopic treatment of ureteric lithiasis. Analysis of 354 urs procedures in a community hospital Acta Urologica Belgica. 1998; 66: 33-40

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Eden, C.G., Mark, I.R., Gupta, R.R., Eastman, J., Shrotri, N.C., Tiptaft, R.C. Intracorporeal or extracorporeal lithotripsy for distal ureteral calculi? Effect of stone size and multiplicity on success rates Journal of Endourology. 1998; 12: 307-312 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. 2003; 58: 990-4 Eichel, L., Batzold, P., Erturk, E. Operator experience and adequate anesthesia improve treatment outcome with third-generation lithotripters Journal of Endourology. 2001; 15: 671-3 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. 1996; 156: 1581-1585 Elashry, O.M., Elbahnasy, A.M., Rao, G.S., Nakada, S.Y., Clayman, R.V. Flexible ureteroscopy: Washington University experience with the 9.3F and 7.5F flexible ureteroscopes. Journal of Urology. 1997; 157: 2074-2080 Elsobky, E., Sheir, K.Z., Madbouly, K., Mokhtar, A.A. Extracorporeal shock wave lithotripsy in children: experience using two second-generation lithotripters BJU International. 2000; 86: 851856 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 & Nephrology. 2003; 37: 129-33 Erhard, M., Salwen, J., Bagley, D.H. Ureteroscopic removal of mid and proximal ureteral calculi Journal of Urology. 1996; 155: 38-42 Ferraro, R.F., Abraham, V.E., Cohen, T.D., Preminger, G.M. A new generation of semirigid fiberoptic ureteroscopes Journal of Endourology. 1999; 13: 35-40 Feyaerts, A., Rietbergen, J., Navarra, S., Vallancien, G., Guillonneau, B. Laparoscopic ureterolithotomy for ureteral calculi. European Urology: European Urology. 2001; 40: 609-13 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. 2004; 33: 80-3 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. 1995; 48: 760-763 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. 1995; 28: 112-115 Fraser, M., Joyce, A.D., Thomas, D.F., Eardley, I., Clark, P.B. Minimally invasive treatment of urinary tract calculi in children BJU International. 1999; 84: 339-342 Fuselier, H.A., Prats, L., Fontenot, C., Gauthier, A., Jr. Comparison of mobile lithotripters at one institution: healthtronics lithotron, Dornier MFL-5000, and Dornier Doli Journal of Endourology. 1999; 13: 539-542 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. 1995; 29: 273-277 Gaur, D. D., Trivedi, S., Prabhudesai, M. R., Madhusudhana, H. R., Gopichand, M. Laparoscopic ureterolithotomy: technical considerations and long-term follow-up. Bju International. 2002; 89: 339-43

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Geist, E., Schmidt, A., Volz, C., Eisenberger, F. The Dornier-Lithotripter U30. First clinical experience Archivos Espanoles De Urologia. 1996; 49: 437-441 Ghobish, A. In situ extracorporeal shockwave lithotripsy of middle and lower ureteral stones: a boosted, stentless, ventral technique European Urology. 1998; 34: 93-98 Gnanapragasam, V.J., Ramsden, P.D., Murthy, L.S., Thomas, D.J. Primary in situ extracorporeal shock wave lithotripsy in the management of ureteric calculi: results with a third-generation lithotripter BJU International. 1999; 84: 770-774 Goel, A., Hemal, A. K. Upper and mid-ureteric stones: a prospective unrandomized comparison of retroperitoneoscopic and open ureterolithotomy Bju International. 2001; 88: 679-82 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 Endourology. 2005; 19: 54-7 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. 1996; 10: 403406 Gofrit, O. N., Pode, D., Meretyk, S., Katz, G., Shapiro, A., Golijanin, D., Wiener, D. P., Shenfeld, O. Z., Landau, E. H. Is the pediatric ureter as efficient as the adult ureter in transporting fragments following extracorporeal shock wave lithotripsy for renal calculi larger than 10 mm.? Journal of Urology. 2001; 166: 1862-4 Goktas, S., Peukirciolu, L., Tahmaz, L., Kibar, Y., Erduran, D., Harmankaya, C. Is there significance of the choice of prone versus supine position in the treatment of proximal ureter stones with extracorporeal shock wave lithotripsy? European Urology. 2000; 38: 618-620 Gomha, M. A., Sheir, K. Z., Showky, S., Abdel-Khalek, M., Mokhtar, A. A., Madbouly, K. Can we improve the prediction of stone-free status after extracorporeal shock wave lithotripsy for ureteral stones? A neural network or a statistical model?. Journal of Urology. 2004; 172: 175-9 Gould, D.L. Holmium:YAG laser and its use in the treatment of urolithiasis: our first 160 cases Journal of Endourology. 1998; 12: 23-26 Grasso, M. Experience with the holmium laser as an endoscopic lithotrite Urology. 1996; 48: 199206 Grasso, M., Bagley, D. Small diameter, actively deflectable, flexible ureteropyeloscopy. Journal of Urology. 1998; 160: 1648-1654 Gronau, E., Pannek, J., Bohme, M., Senge, T. Results of extracorporeal shock wave lithotripsy with a new electrohydraulic shock wave generator. Urologia Internationalis. 2003; 71: 355-60 Gross, A.J., Kugler, A., Seseke, F., Ringert, R.H. Push and smash increases success rates in treatment of ureteric calculi by ESWL International Urology & Nephrology. 1998; 30: 417-421 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. 1996; 56: 241-245 Gur, U., Lifshitz, D. A., Lask, D., Livne, P. M. Ureteral ultrasonic lithotripsy revisited: a neglected tool?. [Review] [18 refs] Journal of Endourology. 2004; 18: 137-40 Hamano, S., Nomura, H., Kinsui, H., Oikawa, T., Suzuki, N., Tanaka, M., Murakami, S., Igarashi, T., Ito, H. Experience with ureteral stone management in 1,082 patients using semirigid ureteroscopes Urologia Internationalis. 2000; 65: 106-111

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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 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 Wong, M.Y. Evolving technique of percutaneous nephrolithotomy in a developing country: Singapore General Hospital experience Journal of Endourology. 1998; 12: 397-401 Wu, C. F., Chen, C. S., Lin, W. Y., Shee, J. J., Lin, C. L., Chen, Y., Huang, W. S. Therapeutic options for proximal ureter stone: extracorporeal shock wave lithotripsy versus semirigid ureterorenoscope with holmium:yttrium-aluminum-garnet laser lithotripsy Urology. 2005; 65: 10759 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. 2004; 172: 1899-902 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 Yang, S.S., Hong, J.S. Electrohydraulic lithotripsy of upper ureteral calculi with semirigid ureteroscope Journal of Endourology. 1996; 10: 27-30 Yaycioglu, O., Guvel, S., Kilinc, F., Egilmez, T., Ozkardes, H. Results with 7.5f Versus 10f rigid ureteroscopes in treatment of ureteral calculi. Urology. 2004; 64: 643-7 Yeniyol, C.O., Ayder, A.R., Minareci, S., Cicek, S., Suelozgen, T. Comparision of intracorporeal lithotripsy methods and forceps use for distal ureteral stones: seven years experience International Urology & Nephrology. 2000; 32: 235-239 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. 2005; 173: 2010-2 Yilmaz, E., Batislam, E., Basar, M., Tuglu, D., Mert, C., Basar, H. Optimal frequency in extracorporeal shock wave lithotripsy: prospective randomized study. Urology. 2005; 66: 1160-4 Yinghao, S., Linhui, W., Songxi, Q., Guoqiang, L., Chuanliang, X., Xu, G., Yongjiang, M. Treatment of urinary calculi with ureteroscopy and Swiss lithoclast pneumatic lithotripter: report of 150 cases Journal of Endourology. 2000; 14: 281-283 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 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. 1996; 19: 103-106 Zargooshi, J. Open stone surgery in children: is it justified in the era of minimally invasive therapies? Bju International. 2001; 88: 928-31 Zeng, G. Q., Zhong, W. D., Cai, Y. B., Dai, Q. S., Hu, J. B., Wei, H. A. Extracorporeal shock-wave versus pneumatic ureteroscopic lithotripsy in treatment of lower ureteral calculi. Asian Journal of Andrology. 2002; 4: 303-5

9013

8310

20034

17104

11130

7441

18600

10065

18204

19856

9422

8109

7047

11132

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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

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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

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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 administration for ureteral stone targeting during shockwave lithotripsy. Journal of Endourology. ; 11: 1637561 Kostakopoulos, A., Stavropoulos, N.I., Louras, G., Deliveliotis, C., Dimopoulos, C. Experience in 3,500 patients with urinary stones treated with the Dornier HM-4 bath-free lithotriptor. International Urology & 7594 Oktay, B., Yavascaoglu, I., Simsek, U., Ozyurt, M. Intracorporeal pneumatic lithotripsy for ureteral and vesical calculi. Scandinavian Journal of Urology & Nephrology. ; 31: 333-336 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. ; 158: 1357-1361 7632 Segura, J.W., Preminger, G.M., Assimos, D.G., Dretler, S.P., Kahn, R.I., Lingeman, J.E., Macaluso, J.N., Jr. Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. Journal of Urology. ; 158: 1915-1921 7665 Bichler, K.H., Lahme, S., Strohmaier, W.L. Indications for open stone removal of urinary calculi. Urologia Internationalis. ; 59: 102-108 7682 Singal, R.K., Razvi, H.A., Denstedt, J.D. Secondary ureteroscopy: results and management strategy at a referral center. Journal of Urology. ; 159: 52-55 7686 al Busaidy, S.S., Prem, A.R., Medhat, M. Paediatric ureteroscopy for ureteric calculi: a 4-year experience. British Journal of Urology. ; 80: 797-801 7725 Mathes, G.L., Jr., Mathes, L.T. High-energy v low-energy shockwave lithotripsy in treatment of ureteral calculi. Journal of Endourology. ; 11: 319-321 7727 Murthy, P.V., Rao, H.S., Meherwade, S., Rao, P.V., Srivastava, A., Sasidharan, K. Ureteroscopic lithotripsy using mini-endoscope and Swiss lithoclast: experience in 147 cases. Journal of Endourology. ; 11: 327-330 7730 Osti, A.H., Hofmockel, G., Frohmuller, H. Ureteroscopic treatment of ureteral stones: only an auxiliary measure of extracorporeal shockwave lithotripsy or a primary therapeutic option?. Urologia Internationalis. ; 7733 Pearle, M.S., Sech, S.M., Cobb, C.G., Riley, J.R., Clark, P.J., Preminger, G.M., Drach, G.W., Roehrborn, C.G. Safety and efficacy of the Alexandrite laser for the treatment of renal and ureteral calculi. Urology. ; 51: 337742 Sinha, R., Sharma, N. Retroperitoneal laparoscopic management of urolithiasis. Journal of Laparoendoscopic and Advanced Surgical Techniques. Part A. ; 7: 95-98 7775 Roberts, W.W., Cadeddu, J.A., Micali, S., Kavoussi, L.R., Moore, R.G. Ureteral stricture formation after removal of impacted calculi. Journal of Urology. ; 159: 723-726

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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, 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. ; 81: 31-35 7805 Daehlin, L., Hellang, M., Ulvik, N.M. Shock wave lithotripsy of urinary calculi with Lithocut C-3000 in a small center. International Urology & Nephrology. ; 29: 617-621 7858 Gould, D.L. Holmium:YAG laser and its use in the treatment of urolithiasis: our first 160 cases. Journal of Endourology. ; 12: 23-26 7863 Hamano, S., Tanaka, M., Suzuki, N., Shiomi, K., Igarashi, T., Murakami, S. Transurethral ureterolithotomy in 100 lower ureteral stones. Urologia Internationalis. ; 60: 53-55 7882 Nazli, O., Cal, C., Ozyurt, C., Gunaydin, G., Cureklibatir, I., Avcieri, V., Erhan, O. Results of extracorporeal shock wave lithotripsy in the pediatric age group. European Urology. ; 33: 333-336 7883 Nguyen, T.A., Belis, J.A. Endoscopic management of urolithiasis in the morbidly obese patient. Journal of Endourology. ; 12: 33-35 7909 Turk, I., Deger, S., Roigas, J., Fahlenkamp, D., Schonberger, B., Loening, S.A. Laparoscopic ureterolithotomy. Techniques in Urology. ; 4: 29-34 8008 Shokeir, A.A., Mutabagani, H. Rigid ureteroscopy in pregnant women. British Journal of Urology. ; 81: 678-681 8013 Teh, C.L., Zhong, P., Preminger, G.M. Laboratory and clinical assessment of pneumatically driven intracorporeal lithotripsy. Journal of Endourology. ; 12: 163-169 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. ; 82: 90-96 8036 Ghobish, A. In situ extracorporeal shockwave lithotripsy of middle and lower ureteral stones: a boosted, stentless, ventral technique. European Urology. ; 34: 93-98 8066 Harmon, W.J., Sershon, P.D., Blute, M.L., Patterson, D.E., Segura, J.W. Ureteroscopy: current practice and long-term complications.. Journal of Urology. ; 157: 28-32 8084 Huang, S., Patel, H., Bellman, G.C. Cost effectiveness of electrohydraulic lithotripsy v Candela pulsed-dye laser in management of the distal ureteral stone. Journal of Endourology. ; 12: 237-240 8106 Vorreuther, R., Klotz, T., Heidenreich, A., Nayal, W., Engelmann, U. Pneumatic v electrokinetic lithotripsy in treatment of ureteral stones. Journal of Endourology. ; 12: 233-236 8109 Yip, K.H., Lee, C.W., Tam, P.C. Holmium laser lithotripsy for ureteral calculi: an outpatient procedure. Journal of Endourology. ; 12: 241-246 8132 Devarajan, R., Ashraf, M., Beck, R.O., Lemberger, R.J., Taylor, M.C. Holmium: YAG lasertripsy for ureteric calculi: an experience of 300 procedures. British Journal of Urology. ; 82: 342-347 8134 Eden, C.G., Mark, I.R., Gupta, R.R., Eastman, J., Shrotri, N.C., Tiptaft, R.C. Intracorporeal or extracorporeal lithotripsy for distal ureteral calculi? Effect of stone size and multiplicity on success rates. Journal of 8164 Tan, P.K., Tan, S.M., Consigliere, D. Ureteroscopic lithoclast lithotripsy: a cost-effective option. Journal of Endourology. ; 12: 341-344 8242 du Fosse, W., Billiet, I., Mattelaer, J. Ureteroscopic treatment of ureteric lithiasis. Analysis of 354 urs procedures in a community hospital. Acta Urologica Belgica. ; 66: 33-40 8255 Kupeli, B., Biri, H., Isen, K., Onaran, M., Alkibay, T., Karaoglan, U., Bozkirli, I. Treatment of ureteral stones: comparison of extracorporeal shock wave lithotripsy and endourologic alternatives. European Urology. ; 34: 8299 Mugiya, S., Ohhira, T., Un-No, T., Takayama, T., Suzuki, K., Fujita, K. Endoscopic management of upper urinary tract disease using a 200-microm holmium laser fiber: initial experience in Japan. Urology. ; 53: 608300 Niall, O., Russell, J., MacGregor, R., Duncan, H., Mullins, J. A comparison of noncontrast computerized tomography with excretory urography in the assessment of acute flank pain. Journal of Urology. ; 161: 534-537

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8307 Tawfiek, E.R., Bagley, D.H. Management of upper urinary tract calculi with ureteroscopic techniques. Urology. ; 53: 25-31 8310 Wong, M.Y. Evolving technique of percutaneous nephrolithotomy in a developing country: Singapore General Hospital experience. Journal of Endourology. ; 12: 397-401 8316 Larkin, G.L., Peacock, W.F., Pearl, S.M., Blair, G.A., D'Amico, F. Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. American Journal of Emergency Medicine. ; 17: 6-10 8363 Hosking, D.H., McColm, S.E., Smith, W.E. Is stenting following ureteroscopy for removal of distal ureteral calculi necessary?. Journal of Urology. ; 161: 48-50 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. ; 161: 45-47 8383 Elashry, O.M., Elbahnasy, A.M., Rao, G.S., Nakada, S.Y., Clayman, R.V. Flexible ureteroscopy: Washington University experience with the 9.3F and 7.5F flexible ureteroscopes.. Journal of Urology. ; 157: 2074-2080 8398 Grasso, M., Bagley, D. Small diameter, actively deflectable, flexible ureteropyeloscopy.. Journal of Urology. ; 160: 1648-1654 8454 Beaghler, M., Poon, M., Ruckle, H., Stewart, S., Weil, D. Complications employing the holmium:YAG laser. Journal of Endourology. ; 12: 533-535 8472 Knispel, H.H., Klan, R., Heicappell, R., Miller, K. Pneumatic lithotripsy applied through deflected working channel of miniureteroscope: results in 143 patients. Journal of Endourology. ; 12: 513-515 8477 Lopez-Alcina, E., Broseta, E., Oliver, F., Boronat, F., Jimenez-Cruz, J.F. Paraureteral extrusion of calculi after endoscopic pulsed-dye laser lithotripsy. Journal of Endourology. ; 12: 517-521 8479 Park, H., Park, M., Park, T. Two-year experience with ureteral stones: extracorporeal shockwave lithotripsy v ureteroscopic manipulation. Journal of Endourology. ; 12: 501-504 8481 Reiter, W.J., Schon-Pernerstorfer, H., Dorfinger, K., Hofbauer, J., Marberger, M. Frequency of urolithiasis in individuals seropositive for human immunodeficiency virus treated with indinavir is higher than previously assumed. Journal of Urology. ; 161: 1082-1084 8504 Ferraro, R.F., Abraham, V.E., Cohen, T.D., Preminger, G.M. A new generation of semirigid fiberoptic ureteroscopes. Journal of Endourology. ; 13: 35-40 8517 Mahmood, N., Turner, W., Rowgaski, K., Almond, D. The patients perspective of extracorporeal shock wave lithotripsy. International Urology & Nephrology. ; 30: 671-675 8523 Rhee, B.K., Bretan, P.N., Jr., Stoller, M.L. Urolithiasis in renal and combined pancreas/renal transplant recipients. Journal of Urology. ; 161: 1458-1462 8527 Scarpa, R.M., De Lisa, A., Porru, D., Usai, E. Holmium:YAG laser ureterolithotripsy. European Urology. ; 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. ; 13: 77-81 8660 Motola, J.A., Smith, A.D. Complications of ureteroscopy: prevention and treatment. AUA Update Series, 11:162, lesson 21. ; : 8697 Pardalidis, N.P., Kosmaoglou, E.V., Kapotis, C.G. Endoscopy vs. extracorporeal shockwave lithotripsy in the treatment of distal ureteral stones: ten years' experience. Journal of Endourology. ; 13: 161-164 8701 Robert, M., Rakotomalala, E., Delbos, O., Navratil, H. Piezoelectric lithotripsy of ureteral stones: influence of shockwave frequency on sedation and therapeutic efficiency. Journal of Endourology. ; 13: 157-160 8771 Puppo, P., Ricciotti, G., Bozzo, W., Introini, C. Primary endoscopic treatment of ureteric calculi. A review of 378 cases. European Urology. ; 36: 48-52 8788 Miller, O.F., Kane, C.J. Time to stone passage for observed ureteral calculi: a guide for patient education. Journal of Urology. ; 162: 688-691

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8793 Bendhack, M.L., Grimm, M.O., Ackermann, R., Vogeli, T. Primary treatment of ureteral stones by new multiline lithotripter. Journal of Endourology. ; 13: 339-342 8800 Fraser, M., Joyce, A.D., Thomas, D.F., Eardley, I., Clark, P.B. Minimally invasive treatment of urinary tract calculi in children. BJU International. ; 84: 339-342 8805 Jayanthi, V.R., Arnold, P.M., Koff, S.A. Strategies for managing upper tract calculi in young children. Journal of Urology. ; 162: 1234-1237 8806 Joshi, H.B., Obadeyi, O.O., Rao, P.N. A comparative analysis of nephrostomy, JJ stent and urgent in situ extracorporeal shock wave lithotripsy for obstructing ureteric stones. BJU International. ; 84: 264-269 8807 Keeley, F.X., Jr., Pillai, M., Smith, G., Chrisofos, M., Tolley, D.A. Electrokinetic lithotripsy: safety, efficacy and limitations of a new form of ballistic lithotripsy. BJU International. ; 84: 261-263 8812 Menezes, P., Dickinson, A., Timoney, A.G. Flexible ureterorenoscopy for the treatment of refractory upper urinary tract stones. BJU International. ; 84: 257-260 8818 Richter, S., Shalev, M., Lobik, L., Buchumensky, V., Nissenkorn, I. Early postureteroscopy vesicoureteral reflux--a temporary and infrequent complication: prospective study. Journal of Endourology. ; 13: 365-366 8840 Karod, J.W., Danella, J., Mowad, J.J. Routine radiologic surveillance for obstruction is not required in asymptomatic patients after ureteroscopy. Journal of Endourology. ; 13: 433-436 8841 Maheshwari, P.N., Oswal, A.T., ankar, M., Nanjappa, K.M., Bansal, M. Is antegrade ureteroscopy better than retrograde ureteroscopy for impacted large upper ureteral calculi?. Journal of Endourology. ; 13: 441-444 8847 Robert, M., Lanfrey, P., Rey, G., Guiter, J., Navratil, H. Analgesia in piezoelectric SWL: comparative study of kidney and upper ureter treatments. Journal of Endourology. ; 13: 391-395 8948 Peschel, R., Janetschek, G., Bartsch, G. Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study [see comments]. Journal of Urology. ; 162: 1909-1912 8956 Kourambas, J., Delvecchio, F. C., Preminger, G. M. Low-power holmium laser for the management of urinary tract calculi, structures, and tumors. Journal of Endourology. ; 15: 529-32 9001 Reddy, P.P., Barrieras, D.J., Bagli, D.J., McLorie, G.A., Khoury, A.E., Merguerian, P.A. Initial experience with endoscopic holmium laser lithotripsy for pediatric urolithiasis. Journal of Urology. ; 162: 1714-1716 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. ; 162: 1717-1720 9036 Gnanapragasam, V.J., Ramsden, P.D., Murthy, L.S., Thomas, D.J. Primary in situ extracorporeal shock wave lithotripsy in the management of ureteric calculi: results with a third-generation lithotripter. BJU International. 9043 Keeley, F.X., Gialas, I., Pillai, M., Chrisofos, M., Tolley, D.A. Laparoscopic ureterolithotomy: the Edinburgh experience. BJU International. ; 84: 765-769 9051 Nualyong, C., Taweemonkongsap, T. Laparoscopic ureterolithotomy for upper ureteric calculi. Journal of the Medical Association of Thailand. ; 82: 1028-1033 9057 Taari, K., Lehtoranta, K., Rannikko, S. Holmium:YAG laser for urinary stones. Scandinavian Journal of Urology & Nephrology. ; 33: 295-298 9092 Fuselier, H.A., Prats, L., Fontenot, C., Gauthier, A., Jr. Comparison of mobile lithotripters at one institution: healthtronics lithotron, Dornier MFL-5000, and Dornier Doli. Journal of Endourology. ; 13: 539-542 9123 Strohmaier, W.L., Schubert, G., Rosenkranz, T., Weigl, A. Comparison of extracorporeal shock wave lithotripsy and ureteroscopy in the treatment of ureteral calculi: a prospective study. European Urology. ; 36: 9127 Virgili, G., Mearini, E., Micali, S., Miano, R., Vespasiani, G., Porena, M. Extracorporeal piezoelectric shockwave lithotripsy of ureteral stones: are second-generation lithotripters obsolete?. Journal of 9256 Gross, A.J., Kugler, A., Seseke, F., Ringert, R.H. Push and smash increases success rates in treatment of ureteric calculi by ESWL. International Urology & Nephrology. ; 30: 417-421

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9272 Matsuoka, K., Iida, S., Inoue, M., Yoshii, S., Arai, K., Tomiyasu, K., Noda, S. Endoscopic lithotripsy with the holmium:YAG laser. Lasers In Surgery & Medicine. ; 25: 389-395 9275 Nakada, S.Y., Jerde, T.J., Bjorling, D.E., Saban, R. Selective cyclooxygenase-2 inhibitors reduce ureteral contraction in vitro: A better alternative for renal colic?. Journal of Urology. ; 163: 607-612 9312 Irving, S.O., Calleja, R., Lee, F., Bullock, K.N., Wraight, P., Doble, A. Is the conservative management of ureteric calculi of > 4 mm safe?. BJU International. ; 85: 637-640 9316 Keating, M.A., Heney, N.M., Young II, H.H., Kerr, J., WS, O'Leary, M.P., Dretler, S.P. Ureteroscopy: the initial experience. Journal of Urology. ; 135: 689-693 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 to size and location of stones. Journal of Endourology. ; 14: 239-246 9393 Delvecchio, F.C., Kuo, R.L., Preminger, G.M. Clinical efficacy of combined lithoclast and lithovac stone removal during ureteroscopy. Journal of Urology. ; 164: 40-42 9422 Yinghao, S., Linhui, W., Songxi, Q., Guoqiang, L., Chuanliang, X., Xu, G., Yongjiang, M. Treatment of urinary calculi with ureteroscopy and Swiss lithoclast pneumatic lithotripter: report of 150 cases. Journal of 9441 Menezes, P., Kumar, P.V., Timoney, A.G. A randomized trial comparing lithoclast with an electrokinetic lithotripter in the management of ureteric stones. BJU International. ; 85: 22-25 9464 Nutahara, K., Kato, M., Miyata, A., Murata, A., Okegawa, T., Miura, I., Kojima, M., Higashihara, E. Comparative study of pulsed dye laser and pneumatic lithotripters for transurethral ureterolithotripsy. International Journal of Urology. ; 7: 172-175 9469 Lorberboym, M., Kapustin, Z., Elias, S., Nikolov, G., Katz, R. The role of renal scintigraphy and unenhanced helical computerized tomography in patients with ureterolithiasis. European Journal of Nuclear Medicine. ; 9471 Kupeli, B., Alkibay, T., Sinik, Z., Karaolan, U., Bozkirli, I. What is the optimal treatment for lower ureteral stones larger than 1 cm?. International Journal of Urology. ; 7: 167-171 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. Journal of Urology. 9540 Mugiya, S., Nagata, M., Un-No, T., Takayama, T., Suzuki, K., Fujita, K. Endoscopic management of impacted ureteral stones using a small caliber ureteroscope and a laser lithotriptor. Journal of Urology. ; 164: 9589 Rane, A., Cahill, D., Larner, T., Saleemi, A., Tiptaft, R. To stent or not to stent? That is still the question. Journal of Endourology. ; 14: 479-481 9598 Ather, M.H., Memon, A. Therapeutic efficacy of Dornier MPL 9000 for prevesical calculi as judged by efficiency quotient. Journal of Endourology. ; 14: 551-553 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. ; 14: 559-564 9607 Dretler, S.P. Ureteroscopy for proximal ureteral calculi: prevention of stone migration. Journal of Endourology. ; 14: 565-567 9608 Elsobky, E., Sheir, K.Z., Madbouly, K., Mokhtar, A.A. Extracorporeal shock wave lithotripsy in children: experience using two second-generation lithotripters. BJU International. ; 86: 851-856 9650 Goktas, S., Peukirciolu, L., Tahmaz, L., Kibar, Y., Erduran, D., Harmankaya, C. Is there significance of the choice of prone versus supine position in the treatment of proximal ureter stones with extracorporeal shock wave lithotripsy?. European Urology. ; 38: 618-620 9663 Cooper, J.T., Stack, G.M., Cooper, T.P. Intensive medical management of ureteral calculi. Urology. ; 56: 9709 Hamano, S., Nomura, H., Kinsui, H., Oikawa, T., Suzuki, N., Tanaka, M., Murakami, S., Igarashi, T., Ito, H. Experience with ureteral stone management in 1,082 patients using semirigid ureteroscopes. Urologia

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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 stones after failed initial treatment. Journal of Urology. ; 164: 1905-1907 9924 Li, J., Kennedy, D., Levine, M., Kumar, A., Mullen, J. Absent hematuria and expensive computerized tomography: case characteristics of emergency urolithiasis. Journal of Urology. ; 165: 782-784 9943 Denstedt, J.D., Wollin, T.A., Sofer, M., Nott, L., Weir, M., D'A Honey, R.J. A prospective randomized controlled trial comparing nonstented versus stented ureteroscopic lithotripsy. Journal of Urology. ; 165: 9949 Hollenbeck, B.K., Schuster, T.G., Faerber, G.J., Wolf, J.S., Jr. Routine placement of ureteral stents is unnecessary after ureteroscopy for urinary calculi. Urology. ; 57: 639-643 9955 Mokhmalji, H., Braun, P.M., Martinez Portillo, F.J., Siegsmund, M., Alken, P., Kohrmann, K.U. Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial. Journal of Urology. ; 165: 1088-1092 9966 Silver, R.I. A fishnet gantry for pediatric extracorporeal shock wave lithotripsy on the Sonolith 3000. Urology. ; 57: 795-797 9994 Buchholz, N.P., van Rossum, M. Shock wave lithotripsy treatment of radiolucent ureteric calculi with the help of contrast medium. European Urology. ; 39: 200-203 10009 Landau, E.H., Gofrit, O.N., Shapiro, A., Meretyk, S., Katz, G., Shenfeld, O.Z., Golijanin, D., Pode, D. Extracorporeal shock wave lithotripsy is highly effective for ureteral calculi in children. Journal of Urology. ; 10065 Yeniyol, C.O., Ayder, A.R., Minareci, S., Cicek, S., Suelozgen, T. Comparision of intracorporeal lithotripsy methods and forceps use for distal ureteral stones: seven years experience. International Urology & 10122 Schuster, T.G., Hollenbeck, B.K., Faerber, G.J., Wolf, J.S., Jr. Complications of ureteroscopy: analysis of predictive factors. Journal of Urology. ; 166: 538-540 10124 Singh, I., Gupta, N.P., Hemal, A.K., Dogra, P.N., Ansari, M.S., Seth, A., Aron, M. Impact of power index, hydroureteronephrosis, stone size, and composition on the efficacy of in situ boosted ESWL for primary proximal ureteral calculi. Urology. ; 58: 16-22 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. ; 10182 Hendrikx, A.J., Strijbos, W.E., de Knijff, D.W., Kums, J.J., Doesburg, W.H., Lemmens, W.A. Treatment for extended-mid and distal ureteral stones: SWL or ureteroscopy? Results of a multicenter study. Journal of Endourology. ; 13: 727-733 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. ; 15: 285-290 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. ; 39: 702-708 10284 Kiyota, H., Ikemoto, I., Asano, K., Madarame, J., Miki, K., Yoshino, Y., Hasegawa, T., Ohishi, Y. Retroperitoneoscopic ureterolithotomy for impacted ureteral stone. International Journal of Urology. ; 8: 39110302 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. ; 39: 591-7 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. ; 88: 325-8 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. ; 166: 1651-7 10396 Gofrit, O. N., Pode, D., Meretyk, S., Katz, G., Shapiro, A., Golijanin, D., Wiener, D. P., Shenfeld, O. Z., Landau, E. H. Is the pediatric ureter as efficient as the adult ureter in transporting fragments following extracorporeal shock wave lithotripsy for renal calculi larger than 10 mm.?. Journal of Urology. ; 166: 1862-4

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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. ; 40: 362-71 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. ; 58: 914-8 10564 Matin, S. F., Yost, A., Streem, S. B. Extracorporeal shock-wave lithotripsy: a comparative study of electrohydraulic and electromagnetic units. Journal of Urology. ; 166: 2053-6 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 10668 Netto, N. R., Jr, Ikonomidis, J., Zillo, C. Routine ureteral stenting after ureteroscopy for ureteral lithiasis: is it 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 stone removal.. AJR. American Journal of Roentgenology. ; 147: 393-7 11010 Feyaerts, A., Rietbergen, J., Navarra, S., Vallancien, G., Guillonneau, B. Laparoscopic ureterolithotomy for ureteral calculi.. European Urology: European Urology. ; 40: 609-13 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 International. ; 89: 181-5 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 with third-generation lithotripters. Journal of Endourology. ; 15: 671-3 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. ; 15: 697-9 11132 Zargooshi, J. Open stone surgery in children: is it justified in the era of minimally invasive therapies?. Bju International. ; 88: 928-31 11156 Goel, A., Hemal, A. K. Upper and mid-ureteric stones: a prospective unrandomized comparison of retroperitoneoscopic and open ureterolithotomy. Bju International. ; 88: 679-82

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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 of Endourology. ; 15: 781-785 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 lithotripsy: aetiology, prevention and management. Bju International. ; 88: 675-8 11216 Desai, M. R., Patel, S. B., Desai, M. M., Kukreja, R., Sabnis, R. B., Desai, R. M., Patel, S. H. The Dretler stone cone: a device to prevent ureteral stone migration-the initial clinical experience.. Journal of Urology. ; 11228 Schuster, T. G., Russell, K. Y., Bloom, D. A., Koo, H. P., Faerber, G. J. Ureteroscopy for the treatment of urolithiasis in children. [Review] [20 refs]. Journal of Urology. ; 167: 1813-16 11234 Lotan, Y., Gettman, M. T., Roehrborn, C. G., Cadeddu, J. A., Pearle, M. S. Management of ureteral calculi: a cost comparison and decision making analysis. [Review] [142 refs]. Journal of Urology. ; 167: 1621-9 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. ; 59: 662-7 11368 Gaur, D. D., Trivedi, S., Prabhudesai, M. R., Madhusudhana, H. R., Gopichand, M. Laparoscopic ureterolithotomy: technical considerations and long-term follow-up.. Bju International. ; 89: 339-43 11460 Rodrigues Netto, N., Jr., Longo, J. A., Ikonomidis, J. A., Rodrigues Netto, M. Extracorporeal shock wave lithotripsy in children.. Journal of Urology. ; 167: 2164-6 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 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. ; 167: 1977-80 11476 Lam, J. S., Greene, T. D., Gupta, M. Treatment of proximal ureteral calculi: holmium:yag laser ureterolithotripsy versus extracorporeal shock wave lithotripsy.. Journal of Urology. ; 167: 1972-6 11630 Lingeman, J.E., Preminger, G.M., Berger, Y., Denstedt, J.D., Goldstone, L., Segura, J.W., Auge, B.K., Kuo, R.L. Use of a temporary ureteral drainage stent (TUDS) after uncomplicated ureteroscopy: Results from a preliminary Phase II clinical trial.. Journal of Urology. ; : 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 comparative study.. European Urology. ; 40: 32-37 11760 Bassiri, A., Ahmadnia, H., Darabi, M. R., Yonessi, M. Transureteral lithotripsy in pediatric practice.. Journal of Endourology. ; 16: 257-60 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 stone manipulation.. Journal of Urology. ; 168: 46-50 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

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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.. Journal of Endourology. ; 16: 19-22 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 shockwave lithotripsy after failed distal ureteroscopy.. Journal of Endourology. ; 16: 355-8 12754 Dash, A., Schuster, T. G., Hollenbeck, B. K., Faerber, G. J., Wolf, J. S., Jr Ureteroscopic treatment of renal calculi in morbidly obese patients: a stone-matched comparison.. Urology. ; 60: 393-397 12756 Shoma, A. M., Eraky, I., El-Kenawy, M. R., El-Kappany, H. A. Percutaneous nephrolithotomy in the supine position: technical aspects and functional outcome compared with the prone technique.. Urology. ; 60: 388-92 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 lithotripsy.. Health Physics. ; 83: 847-53 13190 Hochreiter, W. W., Danuser, H., Perrig, M., Studer, U. E. Extracorporeal shock wave lithotripsy for distal ureteral calculi: What a powerful machine can achieve.. Journal of Urology. ; 169: 878-80 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 Urology. ; 169: 480-2 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. Diagnosis, management and pregnancy outcome.. Journal of Reproductive Medicine. ; 48: 28-32 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 suitable for stentless ureteroscopy following treatment of urolithiasis.[Comment].. Journal of Urology. ; 170:

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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 14392 Leveillee, R. J., Lobik, L. Intracorporeal lithotripsy: which modality is best?. [Review] [19 refs]. Current Opinion in Urology. ; 13: 249-53 14424 Zeng, G. Q., Zhong, W. D., Cai, Y. B., Dai, Q. S., Hu, J. B., Wei, H. A. Extracorporeal shock-wave versus pneumatic ureteroscopic lithotripsy in treatment of lower ureteral calculi.. Asian Journal of Andrology. ; 4: 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 extracorporeal shock wave lithotripsy (ESWL) for obstructing ureteral stones.. European Urology. ; 43: 552-5 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 ileal neobladder urinary diversion.[. Journal of Urology. ; 170: 107-10 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.. Journal of Urology. ; 171: 89-91 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 wave lithotripsy as first line treatment alternative for urinary tract stones in children: A large scale 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

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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 of Endourology. ; 17: 887-90 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

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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 of Endourology. ; 18: 1-5 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 imaging after ureteroscopic holmium:yag laser lithotripsy: when is it necessary?.. Canadian Journal of 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 infants.. Canadian Journal of Urology. ; 10: 2051-5 16010 Sozen, S., Kupeli, B., Tunc, L., Senocak, C., Alkibay, T., Karaoglan, U., Bozkirli, I. Management of ureteral stones with pneumatic lithotripsy: report of 500 patients.. Journal of Endourology. ; 17: 721-4 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. ; 31: 286-90 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?. [Review] [18 refs]. Journal of Endourology. ; 18: 137-40 16128 Purohit, R. S., Stoller, M. L. Stone clustering of patients with cystine urinary stone formation.. Urology. ; 63: 16246 Demirbas, M., Kose, A. C., Samli, M., Guler, C., Kara, T., Karalar, M. Extracorporeal shockwave lithotripsy for solitary distal ureteral stones: does the degree of urinary obstruction affect success?.. Journal of Endourology. 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 prediction of stone-free status after extracorporeal shock wave lithotripsy for ureteral stones? A neural network 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 ureterolithotripsy in children.. BJU International. ; 94: 131-3 16394 De Sio, M., Autorino, R., Damiano, R., Oliva, A., Pane, U., D'Armiento, M. Expanding applications of the access sheath to ureterolithotripsy of distal ureteral stones. A frustrating experience.. Urologia Internationalis.. 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 16402 Saita, A., Bonaccorsi, A., Marchese, F., Condorelli, S. V., Motta, M. Our experience with nifedipine and prednisolone as expulsive therapy for ureteral stones.. Urologia Internationalis.. ; 72 Suppl 1:: 43-45 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 failure to visualize the ureter distal to an impacted calculus constitute an impediment to successful lithotripsy?.. Journal of Endourology. ; 18: 431-5 16616 Anagnostou, T., Tolley, D. Management of ureteric stones. [Review] [64 refs]. European Urology. ; 45: 714-

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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

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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 ureteroscopic stone management.. Journal of Urology. ; 174: 1072-4 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. ; 47: 855-9

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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 extracorporeal shock wave lithotripsy.. Urology. ; 66: 1165-8 19856 Yilmaz, E., Batislam, E., Basar, M., Tuglu, D., Mert, C., Basar, H. Optimal frequency in extracorporeal shock wave lithotripsy: prospective randomized study.. Urology. ; 66: 1160-4 20034 Wu, C. F., Chen, C. S., Lin, W. Y., Shee, J. J., Lin, C. L., Chen, Y., Huang, W. S. Therapeutic options for proximal ureter stone: extracorporeal shock wave lithotripsy versus semirigid ureterorenoscope with holmium:yttrium-aluminum-garnet laser lithotripsy. Urology. ; 65: 1075-9

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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 <5 mm 8788 9526 10632 10828 18522 Meta-analysis: 54 12 9 85 3 68% (46 - 85)% 59 27 9 114 15 4mm or less # pts Notes

results at 2 weeks

5-10mm 8788 10632 10828 Meta-analysis: 8 9 31 47% (36 - 59)% 16 15 73 >4 mm

<10mm - not falling into above classes 9663 19 14548 32 Meta-analysis: 59% (45 - 72)%

35 51

Results at 1 week

>10 mm

no data

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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 # Nifedipine 9663 16332 16402 Meta-analysis: 31 24 13 74% (55 - 88)% 35 30 25 <10 mm <15 mm # Stone free # pts Notes

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

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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% 80% 100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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Transfusion

Distal Ureter - SWL - all types Distal Ureter - SWL - in situ Distal Ureter - URS - all types Distal Ureter - URS - mixed flexible 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 <= 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 - URS - all types Proximal Ureter - URS - mixed flexible 0% 20% 40% 60% 80% 100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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Cardiovascular/Pulmonary

Distal Ureter - SWL - all types Distal Ureter - SWL - in situ Distal Ureter - URS - all types Distal Ureter - URS - rigid

Proximal Ureter - SWL - all types Proximal Ureter - SWL - other Proximal Ureter - URS - all types Proximal Ureter - URS - mixed flexible

0%

20%

40%

60%

80%

100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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Overall Significant Complications


Distal Ureter - SWL - all types Distal Ureter - SWL - in situ Distal Ureter - SWL - other Distal Ureter - URS - all types Distal Ureter - URS - mixed flexible Distal Ureter - URS - rigid Distal Ureter <= 10 mm- SWL - all types Distal Ureter <= 10 mm- SWL - in situ Distal Ureter <= 10 mm- SWL - other Distal Ureter <= 10 mm- URS - all types Distal Ureter <= 10 mm- URS - rigid Distal Ureter >= 10 mm- SWL - all types Distal Ureter >= 10 mm- SWL - in situ Distal Ureter >= 10 mm- URS - all types Distal Ureter >= 10 mm- URS - rigid Mid Ureter - SWL - all types Mid Ureter - SWL - in situ Mid Ureter - SWL - other Mid Ureter - URS - all types Mid Ureter - URS - Flexible Mid Ureter - URS - mixed flexible Mid Ureter - URS - rigid Mid Ureter <= 10 mm- SWL - all types Mid Ureter <= 10 mm- SWL - in situ 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 - SWL - all types Proximal Ureter - SWL - in situ Proximal Ureter - SWL - other Proximal Ureter - URS - all types Proximal Ureter - URS - Flexible Proximal Ureter - URS - mixed flexible Proximal Ureter - URS - rigid Proximal Ureter <= 10 mm- SWL - all types 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- SWL - all types Proximal Ureter >= 10 mm- SWL - in situ Proximal Ureter >= 10 mm- URS - all types Proximal Ureter >= 10 mm- URS - mixed flexible Proximal Ureter >= 10 mm- URS - rigid 0% 20% 40% 60% 80% 100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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Sepsis
Distal Ureter - SWL - all types Distal Ureter - SWL - in situ Distal Ureter - SWL - other Distal Ureter - URS - all types Distal Ureter - URS - mixed flexible Distal Ureter - URS - rigid Distal Ureter <= 10 mm- SWL - all types Distal Ureter <= 10 mm- SWL - in situ Distal Ureter <= 10 mm- SWL - other Distal Ureter <= 10 mm- URS - all types Distal Ureter <= 10 mm- URS - rigid 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 - SWL - other Mid Ureter - URS - all types Mid Ureter - URS - Flexible Mid Ureter - URS - mixed flexible Mid Ureter - URS - rigid Mid Ureter <= 10 mm- SWL - all types Mid Ureter <= 10 mm- SWL - other Proximal Ureter - SWL - all types Proximal Ureter - SWL - in situ Proximal Ureter - SWL - other Proximal Ureter - URS - all types Proximal Ureter - URS - Flexible Proximal Ureter - URS - mixed flexible Proximal Ureter - URS - rigid Proximal Ureter <= 10 mm- SWL - all types Proximal Ureter <= 10 mm- SWL - other Proximal Ureter >= 10 mm- SWL - all types Proximal Ureter >= 10 mm- SWL - in situ Proximal Ureter >= 10 mm- URS - all types Proximal Ureter >= 10 mm- URS - rigid 0% 20% 40% 60% 80% 100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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Steinstrasse

Distal Ureter - SWL - All types Distal Ureter - SWL - other

Mid Ureter - SWL - All types Mid Ureter - SWL - other

Proximal Ureter - SWL - All types Proximal Ureter - SWL - in situ Proximal Ureter - SWL - other Proximal Ureter - URS - all types Proximal Ureter - URS - mixed flexible

0%

20%

40%

60%

80%

100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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Ureteral Injury
Distal Ureter - SWL - All types Distal Ureter - SWL - in situ Distal Ureter - URS - all types Distal Ureter - URS - mixed flexible Distal Ureter - URS - rigid 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 - URS - all types Mid Ureter - URS - Flexible Mid Ureter - URS - mixed flexible Mid Ureter - 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 Proximal Ureter - SWL - in situ Proximal Ureter - SWL - other Proximal Ureter - URS - all types Proximal Ureter - URS - Flexible Proximal Ureter - URS - mixed flexible Proximal Ureter - URS - rigid Proximal Ureter <= 10 mm- URS - all types Proximal Ureter <= 10 mm- URS - rigid Proximal Ureter >= 10 mm- URS - all types Proximal Ureter >= 10 mm- URS - rigid 0% 20% 40% 60% 80% 100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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Ureteral Obstruction
Distal Ureter - SWL - all types Distal Ureter - SWL - in situ Distal Ureter - SWL - other Distal Ureter - URS - all types Distal Ureter - URS - rigid Distal Ureter <= 10 mm- SWL - all types Distal Ureter <= 10 mm- SWL - in situ Distal Ureter <= 10 mm- SWL - other 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 - SWL - other Mid Ureter - URS - all types Mid Ureter - URS - mixed flexible Mid Ureter <= 10 mm- SWL - all types Mid Ureter <= 10 mm- SWL - in situ Mid Ureter <= 10 mm- SWL - other Mid Ureter >= 10 mm- SWL - all types Mid Ureter >= 10 mm- SWL - in situ Proximal Ureter - SWL - all types Proximal Ureter - SWL - bypass Proximal Ureter - SWL - in situ Proximal Ureter - SWL - other Proximal Ureter - URS - all types Proximal Ureter <= 10 mm- SWL - all types Proximal Ureter <= 10 mm- SWL - other 0% 20% 40% 60% 80% 100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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UTI
Distal Ureter - SWL - all types Distal Ureter - SWL - in situ Distal Ureter - SWL - other Distal Ureter - URS - all types Distal Ureter - URS - rigid Distal Ureter <= 10 mm- SWL - all types Distal Ureter <= 10 mm- SWL - other Distal Ureter <= 10 mm- URS - all types Distal Ureter <= 10 mm- URS - rigid

Mid Ureter - SWL - all types Mid Ureter - SWL - other Mid Ureter - URS - all types Mid Ureter - URS - rigid Mid Ureter <= 10 mm- SWL - all types Mid Ureter <= 10 mm- SWL - other

Proximal Ureter - SWL - all types Proximal Ureter - SWL - bypass Proximal Ureter - SWL - in situ Proximal Ureter - SWL - other Proximal Ureter - URS - all types Proximal Ureter - URS - mixed flexible Proximal Ureter - URS - rigid Proximal Ureter <= 10 mm- SWL - all types Proximal Ureter <= 10 mm- SWL - other 0% 20% 40% 60% 80% 100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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Stricture
Distal Ureter - SWL - all types Distal Ureter - SWL - in situ Distal Ureter - URS - all types Distal Ureter - URS - mixed flexible Distal Ureter - URS - rigid Distal Ureter <= 10 mm- SWL - all types Distal Ureter <= 10 mm- SWL - in situ Distal Ureter <= 10 mm- URS - all types Distal Ureter <= 10 mm- URS - rigid 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 - URS - rigid 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 - SWL - other Proximal Ureter - URS - all types Proximal Ureter - URS - Flexible Proximal Ureter - URS - mixed flexible Proximal Ureter - URS - rigid Proximal Ureter <= 10 mm- URS - all types Proximal Ureter <= 10 mm- URS - rigid Proximal Ureter >= 10 mm- URS - all types Proximal Ureter >= 10 mm- URS - rigid 0% 20% 40% 60% 80% 100%

Estimated Occurrence Rate with 95% CI CI, Confidence Interval

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