| ObjectiveTo analyse the efficacy of three minimally invasive surgical treatments, transureteroscopic Holmium: YAG laser lithotripsy (URL ) , minimally invasive percutaneous nephrolithotomy (mPCNL) and retroperitoneal laparoscopic ureterolithotomy (RLU) for complicated upper ureteral calculi. To evaluate three methods of superiority and optimal indications.Methods(1)Criteria of cases: 1)Calculi≥1 cm stayed more than 3 months in ureteral. 2) IVU or B ultrasound showed renal pelvis separated≥3.0 cm,or IVU showed renal pelvis nonvisulization. 3)Calculi distal ureteral stricture or serious ureter distortion occurred. 4)Polyps existed aroud calculi, or calculi was impacted or adhered to ureter tightly. Case according more than two of upper conditions was definite as complicated ureteral calculi.(2)90 cases diagnosed unilateral single complicated positive upper ureteral calculi by KUB, B ultrasonic and IVU were assigned to one of three equal groups, URL, mPCNL and RLU, were completed by experienced doctors, respectively.(3)Summarized the operation time, blood loss, postoperative drain removal, postoperative hospital stay, incidence of complications, and calculi clearance rate of three days and 1 month after operation. (4)Used SPSS statistical software 18.0 to analyse with T-test andχ2-test. Measurement data expressed by average±standard deviations. When P < 0.05, the difference was statistically significant.Results(1)In URL group, 1 case converted to RLU because of failure to reach the calculi for serious ureter distortion was excluded from statistics.(2)The mean operation time of URSL, mPCNL and RLU groups was 40.34±9.35min, 59.70±9.10min, 62.83±13.30min, respectively. Statistical analysis showed the operation time of URL group significant lower than mPCNL group and RLU group. No significant difference in the other two groups.(3)The mean blood loss was 8.10±3.38ml, 50.67±9.35ml, 15.17±9.05 ml, respectively. Statistical analysis showed blood loss in RLU group was obviously higher than that in URL group, but obviously lower than that in mPCNL group.(4) The mean postoperative drain removal was 2.86 days1.24±0.44ds, 6.03±0.67ds, 3.00±0ds. The mean postoperative hospital stay was 2.38±0.56, 7.03±0.67 and 5.73±0.98 days, respectively. Statistical analysis showed mean postoperative drain removal and hospital stay in RLU group was obviously longer than that in URL group, but obviously shorter than that in mPCNL group.(5)The incidence of complications were 13.80%, 10.00%, 6.67%, respectively. Ureteral submucosal damage occurred in URL group and mPCNL group was 4 cases and 3 cases, respectively. In RLU group, peritoneal rupture occurred in one case, and urinary leakage in one case but continued only one day. In URL group, migration of Calculi fragment into the renal pelvis occurred in five cases were excluded from complications. On the sixth month of follow up, all patients had no evidence of ureteral stricture. Statistical analysis showed incidence of complications had no significant differences between three groups. (6)The Calculi clearance rate of three days after operation was 82.76%, 100% and 100%, respectively. Patients in URL group need ESWL as auxiliary treatment, and calculi clearance rate reached to 93.10% at 1 month.Statistical analysis showed calculi clearance rate of three days in URL group was obviously lower than that in the other two groups, but there were no significant differences between three groups.(7)No serious complications were encountered. None of patients in three groups need transfer to open operation.ConclusionAll three methods are safe and effective. To URSL, early calculi clearance rate was relatively lower than the other two methods, while it had the smallest invasion and shortest days in hospital. MPCNL with less invasion was particularly suitable for serious ureter distortion or larger calculi difficult to URL, especially those close to the renal pelvis. However, RLU can be used as a salvage procedure after failed URL or mPCNL.
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