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Prevention of retrograde stone migration during ureteroscopy

Nature Clinical Practice Urology volume 3, pages 60–61 (2006)Cite this article

All urologists who perform ureteroscopy for stone disease have had the experience of watching helplessly as a distal or proximal ureteral stone migrates cephalad, just out of reach or sight. Retrograde stone migration results in a longer operating time, more-invasive endoscopy, and an increase in residual stones and the need for secondary procedures, leading to higher morbidity and greater expense. With ureteroscopy now recommended as the preferred treatment modality for upper and lower ureteral stones, the problem of intraprocedural stone migration is magnified.1

The distal ureteral stone (i.e. at or below the iliac vessels) usually causes some proximal ureteral dilatation. Dislodgement of the stone by the ureteroscope or by irrigation, a laser burst, pulsation of a pneumatic lithotriptor, or the spark of an electrohydraulic electrode can propel the stone cephalad, requiring a change from semirigid to flexible ureteroscopy, stenting, or a secondary procedure. A seemingly straightforward distal ureteral stone can rapidly deteriorate into a complicated problem. Data published by endourology specialists indicate that proximal migration requiring a secondary procedure occurs in 4–5% of distal ureteral stone cases; however, the percentage of stones that migrate in general practice is probably significantly higher. Furthermore, published data do not reflect migrating calculi that are successfully treated at the same sitting but require more-invasive procedures, an otherwise unnecessary stent, or the costly use of a flexible ureteroscope (approximately US$500/use). Calculi in the upper ureter (i.e. above the iliac vessels) are even more likely to migrate cephalad during ureteroscopy. Even the Mayo Clinic group reported successful treatment of only 72% of proximal ureteral stones.2 Results in the average urologist's hands are probably not as good. The group from Berlin reported migration in >40% of proximal ureteral stones using a pneumatic lithotriptor, and concluded that the pneumatic device should not be used for mid or proximal ureteral stones.3 With over 7,000 pneumatic lithotriptors in use, this represents a significant problem.

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Authors and Affiliations

  1. Director of the Kidney Stone Center at Massachusetts General Hospital, and Clinical Professor of Surgery (Urology) at Harvard Medical School, Boston, MA, USA

    Stephen P Dretler

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  1. Stephen P Dretler
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Correspondence to Stephen P Dretler.

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Competing interests

Dr Dretler is a consultant to Cook, ACMI, Boston Scientific, and to MedSource/Accellent, the manufacturer of the Stone Cone.

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Dretler, S. Prevention of retrograde stone migration during ureteroscopy. Nat Rev Urol 3, 60–61 (2006). https://doi.org/10.1038/ncpuro0376

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