Extracorporeal shockwave lithotripsy vs ureteroscopy as first-line therapy for patients with single, distal ureteric stones: a prospective randomized study.

Study Type – Therapy (RCT) Level of Evidence 1b OBJECTIVE To compare extracorporeal shockwave lithotripsy (ESWL) and ureteroscopy (URS) as first-line treatments for patients with distal ureteric stones. PATIENTS AND METHODS In all, 273 patients with single, monolateral, radiopaque, distal ureteric stones of 0.5–1.5 cm were enrolled in a prospective randomized trial. Patients were randomized to undergo ESWL (137) or URS (136). The electromagnetic Modulith SLX lithotripter (Storz Medical, Switzerland) was used for ESWL and a semi-rigid ureteroscope was used for URS. Patients in both groups were compared for overall stone-free rates (SFRs), re-treatment rates, need for auxiliary procedures and complication rates. A subgroup analysis was performed in both groups according to stone size of ≤1 cm and >1 cm. RESULTS Patients in the ESWL group achieved a 92.70% overall SFR with a 44.88% re-treatment rate and an 11.02% auxiliary procedure rate. Complications occurred in 15.32% of patients treated with ESWL. Patients in the URS group achieved a 94.85% overall SFR with a re-treatment rate of 7.75% and an auxiliary procedure rate of 18.60%. Complications occurred in 19.11% of patients treated with URS. In the ESWL group, the need for re-treatments and for auxiliary procedures as well as the incidence of complications was significantly higher in patients with stones of >1 cm. In patients with stones of ≤1 cm treated with ESWL the need for re-treatments and for auxiliary procedures as well as the incidence of complications was significantly lower than for those treated with URS. CONCLUSION In centres where both techniques are available, ESWL should be the preferred treatment for patients with single distal ureteric stones of ≤1 cm and URS should be reserved for patients with stones of >1 cm.