Site Overlay

Comparison of minimally invasive percutaneous nephrolithotomy and ureteroscopy in the management of impacted proximal ureteral stones

Volume 10, Issue 2

Original Article / Published: November 2022


О. Gatsev, V. Todorova, К. Hristov, P. Petrov, K. Petkova, D. Petrova, I. Saltirov

Department of Urology and Nephrology, Military Medical Academy, Sofia, Bulgaria


Introduction and objective: Management of large impacted proximal ureteral stones is often challenging due to the presence of mucosal edema, inflammation and angulations of the ureter and other factors which impede stone access, visibility and lithotripsy and can lead to different types of complications. The objective of our study is to compare the efficacy and safety of minimally invasive percutaneous nephrolithotripsy (mini-PCNL) and ureteroscopy (URS) in the treatment of impacted proximal ureteral stones.

Material and methods: The medical records of 345 patients with impacted proximal ureteral stones 10-20 mm, treated between January 2016 – November 2022 were retrospectively reviewed. 178 patients (51.6%) underwent mini-PCNL, and 167 (48.4%) – URS. Data on patients’ preoperative characteristics, stone-free rates, operating times, intra- and postoperative complications were compared.

Results: Patients’ preoperative characteristics were comparable between the two groups, except for mean stone surface and stone size, which were significantly higher in the mini-PCNL group (respectively, 137.87±44.32mm2 vs 80.94±29.66mm2, p=0.000; and 15.03±2.43 vs 12.02±2.22mm, p=0.000). The stone free rate after single procedure was 94.9% for mini-PCNL and 89,3% in the URS group (p=0,116). Four patients (2.3%) in the mini-PCNL group had significant hemorrhage necessitating selective renovasography and angioembolization of AV fistula. 21 (12.5%) patients had stones showing upward migration during the URS procedure and 3 (1.8%) had partial perforation of the ureteral wall. Hemoglobin drop was significantly higher in mini-PNL group (13.58±12.79g/l vs 4.69±5.72g/l, p=0,000). Mean operative time was significantly longer in the URS group, despite the smaller size of the stones (respectively, 41.41±13.62min vs. 30.67±10.34min, p=0,000). There were statistically significant difference of the necessity of auxiliary procedures in the URS group (respectively, 78 patients (46,4%) vs 6 patients (3.6%), p=0.000).

Conclusions: For an impacted, proximal ureteral stone mini-PNL had better stone-free rates, shorter operative time and low percentage of auxiliary procedure and hospitalizations. However, URS had the advantages  of less invasiveness procedure and shorter postoperative hospital stay.


  1. Gu XJ, Lu JL, Xu Y. Treatment of large impacted proximal ureteral stones: randomized comparison of minimally invasive percutaneous antegrade ureterolithotripsy versus retrograde ureterolithotripsy. World J Urol. 2013 Dec;31(6):1605-10. doi: 10.1007/s00345-013-1026-2.
  2. Tzelves L, Türk C, Skolarikos A. European Association of Urology Urolithiasis Guidelines: Where Are We Going? Eur Urol Focus. 2021 Jan;7(1):34-38. doi: 10.1016/j.euf.2020.09.011.
  3. Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE et al. Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association. J Urol. 1997 Nov;158(5):1915-21. doi: 10.1016/s0022-5347(01)64173-9.
  4. Tiselius HG. 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? Urol Res. 2005 Jun;33(3):185-90. doi: 10.1007/s00240-005-0462-x.
  5. Lam JS, Greene TD, Gupta M. Treatment of proximal ureteral calculi: holmium:YAG laser ureterolithotripsy versus extracorporeal shock wave lithotripsy. J Urol. 2002 May;167(5):1972-6.
  6. Wu CF, Shee JJ, Lin WY, Lin CL, Chen CS. Comparison between extracorporeal shock wave lithotripsy and semirigid ureterorenoscope with holmium:YAG laser lithotripsy for treating large proximal ureteral stones. J Urol. 2004 Nov;172(5 Pt 1):1899-902. doi: 10.1097/01.ju.0000142848.43880.b3.
  7. Kumar V, Ahlawat R, Banjeree GK, Bhaduria RP, Elhence A, Bhandari M. Percutaneous ureterolitholapaxy: the best bet to clear large bulk impacted upper ureteral calculi. Arch Esp Urol. 1996 Jan-Feb;49(1):86-91.
  8. Jackman SV, Docimo SG, Cadeddu JA, Bishoff JT, Kavoussi LR, Jarrett TW. The “mini-perc” technique: a less invasive alternative to percutaneous nephrolithotomy. World J Urol. 1998;16(6):371-4. doi: 10.1007/s003450050083.
  9. Morse RM, Resnick MI. Ureteral calculi: natural history and treatment in an era of advanced technology. J Urol. 1991 Feb;145(2):263-5. doi: 10.1016/s0022-5347(17)38310-6.
  10. Mugiya S, Ozono S, Nagata M, Takayama T, Nagae H. Retrograde endoscopic management of ureteral stones more than 2 cm in size. Urology. 2006 Jun;67(6):1164-8; discussion 1168. doi: 10.1016/j.urology.2006.01.088.
  11. de la Rosette J, Denstedt J, Geavlete P, Keeley F, Matsuda T, Pearle M et al. CROES URS Study Group. The clinical research office of the endourological society ureteroscopy global study: indications, complications, and outcomes in 11,885 patients. J Endourol. 2014 Feb;28(2):131-9. doi: 10.1089/end.2013.0436. Epub 2013 Dec 17. PMID: 24147820.
  12. Juan YS, Shen JT, Li CC, Wang CJ, Chuang SM, Huang CH et al.. Comparison of percutaneous nephrolithotomy and ureteroscopic lithotripsy in the management of impacted, large, proximal ureteral stones. Kaohsiung J Med Sci. 2008 Apr;24(4):204-9. doi: 10.1016/S1607-551X(08)70118-9.
  13. Lai S, Jiao B, Diao T, Seery S, Hu M, Wang M, Hou H, Wang J, Zhang G, Liu M. Optimal management of large proximal ureteral stones (>10 mm): A systematic review and meta-analysis of 12 randomized controlled trials. Int J Surg. 2020 Aug;80:205-217. doi: 10.1016/j.ijsu.2020.06.025.
  14. Goel R, Aron M, Kesarwani PK, Dogra PN, Hemal AK, Gupta NP. Percutaneous antegrade removal of impacted upper-ureteral calculi: still the treatment of choice in developing countries. J Endourol. 2005 Jan-Feb;19(1):54-7. doi: 10.1089/end.2005.19.54.
  15. Li LY, Gao X, Yang M, Li JF, Zhang HB, Xu WF, Lin Z. Does a smaller tract in percutaneous nephrolithotomy contribute to less invasiveness? A prospective comparative study. Urology. 2010 Jan;75(1):56-61. doi: 10.1016/j.urology.2009.06.006.
  16. Chen YT, Chen J, Wong WY, Yang SS, Hsieh CH, Wang CC. Is ureteral stenting necessary after uncomplicated ureteroscopic lithotripsy? A prospective, randomized controlled trial. J Urol. 2002 May;167(5):1977-80.
  17. Nuttall MC, Abbaraju J, Dickinson IK, Sriprasad S. A Review of Studies Reporting on Complications of Upper Urinary Tract Stone Ablation Using the Holmium:YAG Laser. British Journal of Medical and Surgical Urology.2010;3(4):151-159. doi:10.1016/j.bjmsu.2010.01.008
  18. Manohar T, Ganpule A, Desai M. Comparative evaluation of Swiss LithoClast 2 and holmium:YAG laser lithotripsy for impacted upper-ureteral stones. J Endourol. 2008 Mar;22(3):443-6. doi: 10.1089/end.2007.0288.
  19. Matlaga BR, Lingeman JE. Surgical management of upper urinary tract calculi. In: Wein AJ, Kavoussi LR, Partin AW, Novick AC, Peters CA, editors. Campbell-Walsh Urology. 10th ed. Philadelphia: Elsevier Saunders; 2012. pp. 1357–1410. 
  20. Jiang H, Wu Z, Ding Q, Zhang Y. Ureteroscopic treatment of ureteral calculi with holmium: YAG laser lithotripsy. J Endourol. 2007 Feb;21(2):151-4. doi: 10.1089/end.2006.0209
  21. Preminger GM, Tiselius HG, Assimos DG, Alken P, Buck C, Gallucci M et al.; EAU/AUA Nephrolithiasis Guideline Panel. 2007 guideline for the management of ureteral calculi. J Urol. 2007 Dec;178(6):2418-34. doi: 10.1016/j.juro.2007.09.107.
  22. Ziaee SA, Halimiasl P, Aminsharifi A, Shafi H, Beigi FM, Basiri A. Management of 10-15-mm proximal ureteral stones: ureteroscopy or extracorporeal shockwave lithotripsy? Urology. 2008 Jan;71(1):28-31. doi: 10.1016/j.urology.2007.08.025.
  23. Sun X, Xia S, Lu J, Liu H, Han B, Li W. Treatment of large impacted proximal ureteral stones: randomized comparison of percutaneous antegrade ureterolithotripsy versus retrograde ureterolithotripsy. J Endourol. 2008 May;22(5):913-7. doi: 10.1089/end.2007.0230.
  24. Gökce Mİ, Akpinar Ç, Obaid K, Süer E, Gülpinar Ö, Bedük Y. Comparison of retrograde ureterorenoscopy (URS) and percutaneous anterograde ureteroscopy for removal of impacted upper ureteral stones >10mm in the elderly population. Int Braz J Urol. 2021 Jan-Feb;47(1):64-70. doi: 10.1590/S1677-5538.IBJU.2019.0638.
  25. Zhang Y, Yu CF, Jin SH, Zhu H, Na YQ. A prospective comparative study between minimally invasive percutaneous nephrolithotomy in supine position and flexible ureteroscopy in the management of single large stone in the proximal ureter. Urology. 2014 May;83(5):999-1002. doi: 10.1016/j.urology.2013.11.034.
  26. Gao ZM, Gao S, Qu HC, Li K, Li N, Liu CL et al. Minimally invasive percutaneous nephrolithotomy improves stone-free rates for impacted proximal ureteral stones: A systematic review and meta-analysis. PLoS One. 2017 Feb 2;12(2):e0171230. doi: 10.1371/journal.pone.0171230.
  27. Prattley S, Voss J, Cheung S, Geraghty R, Jones P, Somani BK. Ureteroscopy and stone treatment in the elderly (≥70 years): prospective outcomes over 5- years with a review of literature. Int Braz J Urol. 2018 Jul-Aug;44(4):750-757. doi: 10.1590/S1677-5538.IBJU.2017.0516.
  28. Ozgor F, Yanaral F, Savun M, Ozdemir H, Caglar U, Sarilar O. Comparison of miniaturized percutaneous nephrolithotomy and flexible ureterorenoscopy for moderate size renal stones in elderly patients. Kaohsiung J Med Sci. 2018 Jun;34(6):352-356. doi: 10.1016/j.kjms.2017.10.003.
Volume 10, Issue 2


minimally invasive percutaneous nephrolithotomy, ureteroscopy, urolithiasis, proximal impacted stone.

How to cite this article:

Gatsev O, Todorova V, Hristov K, Petrov P, Petrova D, Petkova K, Saltirov I. Comparison of minimally invasive percutaneous nephrolithotomy and ureteroscopy in the management of impacted proximal ureteral stones. Journal of Endourology and Minimally Invasive Surgery (Bulgaria), 2022; 10(2): 55-65

Corresponding author:

Dr Ognyan Gatsev

Department of Urology and Nephrology
Military Medical Academy of Sofia

3 “Georgi Sofiiski” blvd.
Sofia 1606, Bulgaria

E-mail: Web: