Comparison of Primary and Delayed Ureteroscopy for Ureteric Stones: A Prospective Non-randomized Comparative Study

Introduction

The study, titled “Comparison of Primary and Delayed Ureteroscopy for Ureteric Stones: A Prospective Non-Randomized Comparative Study,” aims to compare the effectiveness and outcomes of delayed and immediate ureteroscopy in the treatment of ureteric stone disease. By assessing immediate and delayed ureteroscopy in a non-randomized prospective study design the plan is to give an insight into which method of approach would provide a better patient outcome, in terms of stone clearance rate, complications, and duration of recovery at the end of the study with the ultimate goal of optimizing patient management for ureteric stone disease.

What are Ureteric Stones?

Ureteral stones, also known as kidney stones or renal calculi, are hard deposits of minerals and salts that form in the kidney, from where they descend to the bladder through the Ureter. As the kidney stone succumbs to its destiny, a person experiences a few symptoms, which are known as renal stone symptoms or kidney stone symptoms. The symptoms include pain caused due to change in posture of the body, vomiting, nausea, fluctuation in temperature, etc.

What is Primary Ureteroscopy 

Primary ureteroscopy involves the use of a small probe (ureteroscope) that is passed through the urethra and up into the bladder. The scope is then advanced up the ureter and into the kidney. This primary procedure can diagnose and treat a number of urinary tract problems. It allows the urologist to find and remove ureteric stones without having to make a surgical cut. Ureteroscopy (URS) is a special name given to a primary ureteroscopy that removes or treats the host of their abnormality with open or minimally invasive methods.

What is Delayed Ureteroscopy?

Delayed ureteroscopy (URS) refers to a ureteroscopy (URS) procedure that is performed at a later date following diagnosis of ureteric stones. The delay may be for a number of reasons including the clearance of infection, improvement in the patient’s general medical condition, or for the stone to migrate into a better position for extraction. During this time, patients may be treated with medication to control symptoms or to facilitate spontaneous non-surgical stone passage. The delayed approach is aimed at optimising conditions for a safe and effective ureteroscopic intervention.

Comparison of Primary and Delayed Ureteroscopy for Ureteric Stones

Several factors are considered when comparing primary ureteroscopy and delayed ureteroscopy for ureteric stones.

• Efficiency of Stone Removal: Primary ureteroscopy is often performed as the patient is initially evaluated for an acute stone, and immediate stone removal is possible, which may be the most efficient treatment course in certain cases, particularly for less complex stone burdens and low-risk patients. Initial ureteroscopic intervention is a more efficient approach than performing no stone intervention in these cases, as patients will require future intervention. Delayed ureteroscopy may be the most efficient treatment course for stones that are initially large or in difficult to reach locations.
• Risk of Complications: Potential advantages of immediate ureteroscopy compared to delayed ureteroscopy include a lower morbidity and mortality if an immediate procedure is performed on a larger stone burden or if complications are more likely to arise from the procedure. This advantage may be reduced by common practices of preoperative stenting and use of ureteroscopic antegrade stents that have been shown to be effective at reducing the risks of sepsis.
• Patient Recovery and Outcomes: Immediate intervention will generally provide faster recovery times for patients and resolve the stone issue more quickly. Delaying surgery may prolong the recovery period and sepsis incidence but in select cases allows safer and more effective implementation of surgery.
• Cost and Resource Utilization: Treating patients and resolving their urolithiasis more quickly results in a lower cost for patients overall, as a result of fewer additional treatments and lower rates of procedures on an emergent basis. Temporarily treating patients with larger stone burdens and allowing rescheduled elective procedures to allow preoperative stenting will shift the costs to the near-term, but is likely to be a lower long-term cost.
• Patient Selection: Patient selection can be complex and depends on individual patient factors including stone size and location, overall patient health, and other medical comorbidities.

To sum up, primary and delayed ureteroscopy each has its own merits and demerits. Which process to use depends on assessment of the individual patients, the size and location of the ureteric stones and the relative risk and efficacy of each method.

Decision-Making Factors

Stone Characteristics:

The size, location, and composition of the stones influence the choice between primary and delayed ureteroscopy.

Clinical Presentation:

Symptomatic patients with acute obstruction may benefit from primary ureteroscopy.

Asymptomatic patients or those with less severe symptoms may be candidates for delayed ureteroscopy.

Patient Factors:

Overall health, comorbidities, and willingness to undergo immediate intervention play a role in decision-making.

Monitoring Response:

Serial imaging and clinical monitoring help assess the response to conservative measures, guiding the decision for delayed ureteroscopy.

Resource Availability:

The availability of equipment, expertise, and surgical facilities may influence the timing of the procedure.

Shared Decision-Making:

Involving the patient in the decision-making process, considering their preferences and expectations.

Risk-Benefit Analysis:

Weighing the risks and benefits of immediate intervention versus a delayed approach based on individual patient factors.

Ultimately, the decision between primary and delayed ureteroscopy should be individualized, taking into account the specific clinical scenario and the patient’s overall condition.

Conclusion

In summary, the decision between immediate and delayed ureteroscopy in the management of ureteric calculi is a multifaceted one that is patient specific. For certain patients, immediate ureteroscopy may provide urgent relief, but at a potentially higher risk, as noted in our study. On the other end, delayed ureteroscopy with time for condition optimization allows for definitive treatment but may result in significant patient morbidity in the interim period. The decision between immediate and delayed ureteroscopy should be individualized based on risk stratification, weighing the benefits of stone removal against each patient’s potential risk profile.

Also Read:

Cost of Ureteroscopy (URS) in Bangalore

FAQs

1. What causes ureteric stones?

Ureteric stones are often caused by a concentration of minerals and salts in urine. Factors like dehydration, diet, certain medications, and genetic predisposition can contribute to their formation.

2. Can ureteric stones recur?

Yes, individuals who have had ureteric stones are at higher risk of recurrence. Preventive measures include hydration, dietary changes, and medications.

3. Can ureteric stones pass on their own?

Small stones often pass on their own with adequate hydration and pain management. Larger stones might require medical intervention.

4. Are there any risks associated with ureteroscopy?

Risks include infection, bleeding, ureter damage, and, rarely, kidney damage. However, ureteroscopy is generally safe and effective.

5. What are the symptoms of ureteric stones?

Symptoms include sharp pain in the back or side, pain during urination, cloudy or foul-smelling urine, nausea, vomiting, and the urge to urinate frequently.