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Sir,

We were interested to read this review [1] on the latest trends in managing lower ureteric stones. The authors concluded from their clinical results and literature search that the first-line management for lower ureteric stones for normal uncomplicated cases should be ESWL. We wish to express a contrary view.

Based on the AUA [2] and EUA [3] guidelines on managing ureteric stones the primary approach to distal ureteric stones can be either ESWL or ureteroscopy; this recommendation is evidence-based, after a thorough review of the world literature. The authors indicate a recent prospective trial comparing the two treatment options, and concluded that the two techniques had a similar stone-free rate but morbidity was lower and discharge quicker for ESWL [4]. However, on closer examination the study was closed prematurely and the number of patients recruited far less than that needed to detect a 5–10 % difference in the clinical outcomes. Thus their analysis concentrated on the secondary outcome variables, e.g. operating time, patient satisfaction and cost. Therefore, the equivalent stone-free rate may be related to the power of the study. There was no statistically significant difference in morbidity in the two groups, although trends of more minor complications, postoperative frank pain and dysuria in the ureteroscopy group were more prominent, which may be related to the relatively high stenting rate after ureteroscopy (91%) in that study.

Peschel et al.[5] reported a similar prospective trial on 80 patients with distal ureteric stones randomized to receive treatment by ESWL (using the Dornier MFL 5000 lithotripter) and ureteroscopy. In that study ureteroscopy was significantly better in terms of operative time, fluoroscopy time and time to achieve a stone-free status. Therefore, ureteroscopy appears to be as good as ESWL, if not better, for treating distal ureteric stones. Lotan et al.[6] published an excellent review of the management of ureteric stone, with particular emphasis on the cost of different treatment strategies. In their review the overall mean (range) stone-free rate for distal ureteric stones by ureteroscopy, ESWL using the HM3 lithotripter and ESWL using other lithotripters were 95 (86–100), 89 (79–97) and 82 (59–97)%, respectively. They also concluded that ureteroscopy was more cost-effective at all ureteric stone sites, regardless of the success rate of ESWL.

Complications related to ureteroscopy are of concern when compared with the minimal morbidity of ESWL. However, with advances in ureteroscope design and intracorporeal lithotripsy techniques, this has decreased dramatically. Harmon et al.[7] reported a decrease in the significant complication rate from 6.6% (1982–1985) to 1.5% (1992). In the review of Sofer et al.[8], in 598 patients with ureteric stones treated with ureteroscopy and holmium:YAG laser lithotripsy, the overall complication was 4% (laser-related < 1%).

Undoubtedly, the success rate and complication rate of the two procedures depends on the expertise of the surgeon and availability of equipment. This raises the importance of auditing the treatment outcome in individual centres. The authors’ centre had an excellence outcome in ESWL of distal ureteric stone with a success rate of 95%. Only the mean stone size was reported in the article and it would be interesting to know the number of patients with stones of < 5 mm who were treated within 15 days of referral. As ureteric stones of < 5 mm in diameter have a high chance of spontaneous passage, an initial observational approach was recommended by both the AUA and EUA guidelines. Premature inclusion of these patients may affect the final success rate of treatment.

To provide the best information to the patient, sound evidence-based knowledge of each available treatment option for a particular disease, together with consideration of the availability of equipment, local waiting time, expertise of the surgeon and each patient's situation, is necessary to maintain the highest standard of care.