Comparison of Antegrade and Retrograde Ureterolithotripsy for Proximal Ureteral Stones

A Systematic Review and Meta-analysis

Kazumi Taguchi; Shuzo Hamamoto; Satoshi Osaga; Teruaki Sugino; Rei Unno; Ryosuke Ando; Atsushi Okada; Takahiro Yasui


Transl Androl Urol. 2021;10(3):1179-1191. 

In This Article

Abstract and Introduction


Background: Antegrade percutaneous ureterolithotripsy (URSL) could be a treatment option for large and/or impacted proximal ureteral stones, which are difficult to treat. To review the current approach and treatment outcomes and to compare the efficacy of retrograde and antegrade URSL for large proximal ureteral stones, we evaluated the unique perspectives of both surgical modalities.

Methods: This systematic literature review and meta-analysis was performed in July 2020. Articles on human studies and treatment of ureteral stones with URSL were extracted from the PubMed, MEDLINE, Embase, Cochrane Library, Scopus, and the Japan Medical Abstracts Society databases without any language restrictions. The risks of bias for randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) were assessed using the Cochrane risk of tool and the Risk of Bias in Non-randomized Studies- of Interventions tool, respectively.

Results: A total of 10 studies, including seven RCTs and three non-RCTs, were selected for the analysis; 433 and 420 cases underwent retrograde and antegrade URSL, respectively. The stone-free rate (SFR) was significantly higher in antegrade URSL than in retrograde URSL (SFR ratio: 1.17, 95% CI: 1.12–1.22; P<0.001), while the hospital stay was significantly longer in antegrade URSL than in retrograde URSL (standardized mean difference: 2.56, 95% CI: 0.67–4.46; P=0.008). There were no significant differences in the operation time and the overall complication rate between the two approaches.

Conclusions: Despite the heterogeneity of data and bias limitations, this latest evidence reflects real practice data, which may be useful for decision making.


Innovations in ureteroscopes and laser technology have expanded the global application of ureteroscopy (URS).[1,2] Based on the recommendations of various guidelines, it has become the first option of treatment for ureteral stones.[3] However, treatment of large proximal ureteral stones by URS remains challenging due to concerns regarding the impaction on the ureteral wall, tortuous ureter, and the narrow lumen of the distal ureter.[4] Furthermore, the laser lithotripsy procedure involved could result in the creation of residual fragments or ureteral stenosis.[5]

In addition to URS, percutaneous nephrolithotomy (PCNL) (a form of minimally invasive surgery) has been widely utilized for large renal and proximal ureteral stones.[6] Although thought to be less invasive than open or laparoscopic stone removal, surgeons are sometimes reluctant to proceed with PCNL due to complications related to renal access.[7] A variety of renal access methods, such as ultrasound guidance[8] and miniaturized tract, possibly with the utilization of a flexible nephro- or ureteroscope,[9] could mitigate the major unique complications of PCNL without reducing its efficacy for stone removal. While the European Association of Urology (EAU)[10] and the Urological Association of Asia (UAA)[11] guidelines suggest that antegrade ureterolithotripsy (URSL) may be a good alternative for the treatment of proximal ureteral stones larger than 10 mm, there is still a lack of evidence on the optimal case for the application of antegrade URSL over retrograde URSL in real practice.

To better understand the features of both retrograde and antegrade URSL, we conducted a systematic review and meta-analysis comparing the treatment outcomes between the two surgical modalities in patients with large proximal ureteral stones. The results of the present analysis are the most recently updated and useful for decision-making discussions between the surgical team and patients with large ureteral stones. We present the following article in accordance with the PRISMA reporting checklist (available at[12]