Comment on: Laparoscopic transperitoneal ureterolithotomy for large ureteric stone.

Sir,

I read with great interest the article titled “Laparoscopy transperitoneal ureterolithotomy for large ureteric stone” by Al-Sayyad.[1] The report is very informative, with some insight into the current trend of large proximal ureteric stone management. I have some comments on this work. Due to the nature of retrospective study, the value of this report is limited. The author did not define the meaning of large proximal ureteric stone clearly. In most of previous studies this classification was precise in term of size and site of ureteric stone. As an example Geol et al.[2] classify it as stone located between the ureteropelvic junction and the lower border of the 4th lumbar vertebra, whereas Cengiz et al.[3] use 5 cm distal to the ureteropelvic junction. Goel et al.[2] found that the best option for those types of stone is percutaneous nephrolithotomy (PCNL) which give stone free rate of 98.5%. This success rates were almost similar to laparoscopic ureterolithotomy done by the author.[1] In contrast the laparoscopic ureterolithotomy in this study showed higher morbidity in comparison to the PCNL in Goel et al.[2] These shown by longer operative time (mean of 90 vs. 47 minutes) and longer hospital stay (mean of 62.4 vs. 46 hours).[12] If we treat the patient individually with precise diagnosis of site and size of stone, the choice of treatment mode will be more accurate. Endourology procedures are documented as minimal invasive procedure with very low morbidity, but highly operator dependent. I would say that the best option for stone located close to ureteropelvic junction (5 cm) is PCNL. This endourology procedure will give high success rate with reasonable morbidity in an expert hand. Laparoscopic ureterolithotomy only reserve for those cases which was contraindicated for PCNL.