Discussion
bleeding, upper ureteric stones, Elgebaly, Urosepsis, urosepsis
BLEEDING, UROSEPSIS, COMPLICATION, URETER, UROSEPSIS, COMPLICATIONS
RIRS represents the most common approach for skilled surgeons and for patients as it can be done through the nature orifices and seems to be minimally invasive. However, RIRS has some drawbacks, especially for the management of large impacted upper ureteric stones such as low success rates, need multiple sessions, more complications as a result of a narrow field of vision due to the narrow space around the stone and risk of urosepsis particularly with prolonged operative time [We prospectively designed the present study trying to minimize the drawbacks of antegrade approach especially the bleeding due to its invasive nature by doing a puncture through lower calyx and tract dilatation to 14 fr.So, we think that to the best of our knowledge this is the first study done in prospective manner and totally supine, ultrasonic guided puncture through the lower calyx with 14 fr tract, tubeless for antegrade FURS in the management of impacted large upper ureteric stones ≥ 1.5 cm.In the present series, SFR was higher in the antegrade URS group than in RIRS group after 2 weeks 90.3% vs. 70% p = 0.046. This significant difference may be due to better field of vision as the procedure done through dilated system and the very rare possibility of stone movement. This was close to the rates documented by various studies clarifying the upper hand of antegrade approach such as Liu et al. [In the present study, the operative time was shorter in RIRS group than antegrade FURS group 64.40 (± 7.16) vs 93.55 (± 7.58) min p < 0.001. This significant difference was due to time taken for renal puncture, dilatation of the tract and manipulation for direction of flexible URS until reaching the stone into ureter.This results was congruent with many published studies which reported longer operative time in the antegrade procedure. Elgebaly et al. [In the present study, bleeding less than 150 ml occurred in three cases in antegrade FURS group and all cases managed conservatively and no need for blood transfusion while no cases in RIRS group. As the bleeding is considered the most nightmares of this antegrade URS maneuver due to its invasive nature, but we think that our technique introduce almost safe way for this procedure as we done puncture through lower calyx which carry less risk of bleeding than middle and upper calyceal puncture using ultrasonic guidance with dilatation to only 14 fr. Urosepsis occurred in five cases of RIRS group while no cases in antegrade FURS group confirming that urosepsis is a technique related complication due to high pelvicalyceal pressure as we excluded patient related factor for urosepsis.In literature, the reported overall complications in both groups are comparable. Elgebaly et al. [From our practice we noticed that the antegrade FURS approach is a promising procedure for the management of large impacted upper ureteric stones as minitract (14 Fr) through the lower calyx using ultrasonic guidance carry less risk of bleeding, easy manipulation and direction of flexible URS through the ureter with high SFR. We think that shorter UAS and scopes should be designed for this particular percutaneous procedure in the future. Also, we recommended more studies to compare different instrumentations such as ultraminiPERC sheath and UAS for antegrade approach.The limitations which touched our study, including that the study done in a single center. We hope to see several randomized studies with more number of patients and longer follow up periods from other centers for further confirmation of the safety and efficacy of antegrade FURS in the management of impacted large upper ureteric stones ≥ 1.5 cm.