Treatment options for proximal ureteral urolithiasis: review and recommendations.

The treatment of proximal ureteral calculi has been altered markedly by recent developments in shock wave lithotripsy (bypass, pushback and in situ), ureterorenoscopy and percutaneous stone removal. In an effort to discern the proper role of these newer treatment options with respect to ureterolithotomy (flank approach or dorsal lumbotomy), we completed a multicentered study in which 142 upper ureteral stone patients in 7 different treatment categories were reviewed retrospectively and contacted for convalescence data. From these data we conclude that before extracorporeal shock wave lithotripsy an upper ureteral stone should be manipulated until it is either pushed back to the kidney or bypassed with a stent. This maneuver should result in successful extracorporeal shock wave lithotripsy in more than 90 per cent of the patients. For those few patients with an impacted upper ureteral calculus ureterorenoscopy is recommended. Given the presently available treatment modalities we conclude that less than 3 per cent of all upper ureteral calculi will require ureterolithotomy. In this last circumstance a dorsal lumbotomy incision appears to be less morbid and yet as effective as anterior ureterolithotomy.