Urolithiasis, commonly known as urinary stone disease, is one of the oldest medical conditions affecting humans. The global prevalence of this disease has increased significantly, with notable regional differences. In North America, the prevalence ranges from 7% to 13 %,(1) while in Europe, it varies between 5% and 9%. In Asia, it is reported to be between 1% and 5%, and in India, the lifetime prevalence is estimated at 7.9% (5.7–10.8%).(2) Several factors, including geography, socioeconomic status, dietary habits, and metabolic conditions such as obesity, contribute to the epidemiological variations of urolithiasis.

Obesity has been recognized as a significant risk factor for the development of urinary stones, and metabolic syndrome—comprising central obesity, hyperglycemia, dyslipidemia, and hypertension—is associated with an increased risk of stone formation.(2) The incidence of urolithiasis is particularly high in individuals aged 30–60 years due to occupational dehydration, unhealthy dietary patterns, and lifestyle-related stress.(3) Additionally, the advancement and increased use of high-resolution imaging techniques, such as computed tomography (CT) and ultrasonography, have contributed to the rising detection rates of urinary stones. The most common types of urinary stones include calcium oxalate (75–90%), uric acid (5–20%), calcium phosphate (6–13%), struvite (2–15%), apatite (1%), and cystine (0.5–1%).

Urinary stones can cause severe pain, urinary tract infections, and hydronephrosis, leading to potential renal dysfunction, if left untreated.(2) The obstruction caused by larger or impacted stones can result in complications such as nephrohydrosis, pyonephrosis, and chronic inflammatory changes in the ureter.(4) In some cases, secondary infections and immune responses to foreign material contribute to the development of ureteral strictures and polyps.(1) Given these risks, effective treatment strategies are essential for patient management.

Historically, open surgical procedures were commonly used for stone removal, but modern minimally invasive techniques like Extracorporeal Shock Wave Lithotripsy (ESWL), Ureteroscopic Lithotripsy (URSL), Percutaneous Nephrolithotomy (PCNL) and Retroperitoneoscopic Ureterolithotomy (RPUL) have significantly improved treatment outcomes. However, there is no single gold-standard approach, as treatment selection depends on stone size, location, and patient comorbidities.(5) Discrepancies in international guidelines, such as those from the European Association of Urology (EAU) and the American Urological Association (AUA), further complicate treatment decisions, particularly regarding cut-off values for stone size and first-line treatment recommendations.(5) With advancements in endoscopic technology, the holmium:yttrium-aluminum-garnet (Ho:YAG) laser has become the gold standard for lithotripsy, particularly for ureteroscopic stone management.(4)

Aim and Objectives

Aim:

The aim of this study was to compare the outcomes of Percutaneous Nephrolithotomy (PCNL) and Ureteroscopic Lithotripsy (URSL) in the management of proximal ureteric stones using Holmium Laser.

Objectives:

1. To evaluate stone free rate of PCNL and URSL in managing proximal ureteric stones, using Holmium Laser.
2. To determine the operative time after each procedure.
3. To compare the intra and post-operative complication rates of both procedures.

Study Design: A prospective hospital based observational study

Study Setting: Department of General Surgery, S.N. Medical College, Agra

Sample Selection: Out of all the patients with upper ureteric calculus/calculi, who met the inclusion criteria and admitted under the Department of General Surgery in Sarojini Naidu Medical College, Agra from 1^st October 2023 to 30th September 2024 were eligible for the study.

All patients of either sex in the age group of 18 to 60 years, with upper ureteric stones of size up to 2 cm were included in the study, while patients with concomitant renal stones, or who had undergone previous ipsilateral endourological procedure, or who had ipsilateral pyelonephritis/pyelonephrosis and had uncontrolled co-morbid conditions were excluded from the study.

Study Duration: The study was completed in a period of 24 months from 1^st January 2023 to 31st December 2024.

Sampling method: Quota sampling of the patients satisfying the inclusion criteria was done and all such patients attending the general surgery OPD and emergency from 1st October 2023 to 30th September 2024 were incorporated as the study population.           

Sample Size Calculation: A sample size of 80 was obtained based on the study conducted by Faridi et al (2020)⁽⁶⁾, in which, the prevalence of upper ureteric calculi was found to be 16.6%.

Ethical considerations: Approval of the study was taken from Institutional Ethical Committee of Sarojini Naidu Medical College, Agra (UP).SNMC/IEC/DHR/2025/61. Study participants’ informed written consent was taken prior to starting of the study.

They were randomly divided into 2 groups of 40 participants each. One group underwent mini-PCNL and the other, URSL. They were posted for surgery only after optimization and taking detailed written informed consent for surgery. Each operated case was noted for the duration of surgery, intra operative complications, immediate and early post-operative complications and hospital stay. The residual stone rate was calculated based on the post-operative NCCT KUB finding, done after 3 months of surgery.

Table 1: Demographic Profile of participants

The data suggests that younger individuals (18–40 years) make up the majority of the study participants (65%).The gender distribution clearly signifies male predominance with 56 participants, outnumbering the 24 female participants. The data highlights a gender imbalance among participants, with males constituting 70% and females 30% of the total sample size. The distribution of co-morbidities among study participants shows that 12 of them (15%) have hypertension, whereas 4 participants (5%) have diabetes mellitus.

Table 2: Clinical Outcomes

As evident from the table that PCNL required significantly higher time to complete than URSL. On one hand, in the PCNL group, all 40 participants had a surgery duration of ≥100 minutes, on the other hand, in the URSL group, just 7 participants (17.5%) had a duration of ≥100 minutes, while 33 participants (82.5%) had a surgery duration of <100 minutes. This signifies the higher demanding nature of PCNL in terms of surgeon’s expertise and procedure’s technicalities.

Both, the intraoperative and postoperative complication rates were moreover similar for PCNL, ie., 7.5% each. Whereas, URSL was noted to have a higher, but similar rates for intraoperative and postoperative complication rates, of 12.5%.

Talking about the duration of hospitalization, it was found to be significantly higher for PCNL, with all the 40 participants staying in hospital for at least 6 days, compared to URSL group with only 4 (10%) participants staying for 6 days or more.

The most significant finding of the study remains that of stone clearance rates of both procedures. In the table, PCNL is shown to demonstrate unambiguous superiority over URSL in terms of stone free rates, with 95% stone clearance rate noted after PCNL, compared to 75% noted after URSL.

Table 3: Association between Type of Procedure and Outcome

There was a significant association of duration of surgery with procedure, with PCNL being a lengthier and technically more demanding procedure than URSL.

There was a significant association between duration of hospitalization and procedure performed, with PCNL requiring longer hospital stay than URSL. 90% of URSL participants were discharged within 5 days, while all the PCNL participants were hospitalized for at least 6 days.

There was noted a significant relationship between residual stone rates and procedure. While PCNL demonstrated a lower residual stone rate of just 5%, the rate was significantly higher in URSL with 25%. This established the procedural supremacy of PCNL over URSL in terms of stone clearance rates.

The age distribution of study participants revealed that majority of them fell in the bracket of 18–40 years, ie., 52 (65%). This trend aligns with that observed in a study conducted by Singh et al., published in the Indian Journal of Urology (2019).(7)

The gender distribution in our study revealed a significant male predominance, with 56 males (70%) resulting in a male-to-female ratio of approximately 2.3:1. Similar observation was noted in a study conducted at a tertiary care hospital in eastern India, with a male-to-female ratio of approximately 2:1 for ureteric stones.(8)

The analysis of co-morbidities among the study participants revealed that out of 80 individuals, 12 (15%) had hypertension (HTN), and 4 (5%) had diabetes mellitus (DM). This finding aligns with that observed by Abdulla et al. (2023)(9) and Datta (2019)(10).

The management of proximal ureteric stones requires balancing stone clearance rates against patient morbidity. Our study demonstrated that PCNL provides a significantly higher stone-free rate (95%) compared to URSL (75%) (p=0.012). This finding aligns with previous studies, conducted by Joshi (2019)(11), Deole et al. (2020)(12), Satav et al. (2020)(13), and Hosseini et al. (2015)(14), where PCNL was shown to achieve better clearance, especially for impacted or larger ureteric stones.

However, this benefit comes at the cost of significantly longer operative time and hospital stay. All PCNL cases required ≥100 minutes, and all patients stayed ≥6 days in the hospital. In contrast, URSL showed shorter surgery duration and faster discharge, offering advantages in terms of patient recovery and hospital resource utilization. These findings were in accordance with those noted by Babu et al. (2020)(15), studies conducted in a Delhi hospital(16), Yashoda Hospital(17), Mohammed et al. (2022)(18), and Lu et al. (2021)(19).

Intraoperative and postoperative complication rates were not statistically different between the two groups, supporting the safety of both modalities when performed by experienced surgeons. This goes parallel to the findings of Singh et al. (2024)(20), and Kumar et al. (2021)(21).

These findings suggest that PCNL remains the gold standard when maximal stone clearance is prioritized, particularly in cases of large, impacted stones. Meanwhile, URSL is an excellent option for smaller stones or patients desiring a quicker recovery with minimal hospitalization.

Limitations of this study include the relatively small sample size and single-center design, which may limit generalizability. Future multicentric trials with larger populations are recommended to further refine treatment guidelines for proximal ureteric stones.

Both PCNL and URSL are effective for managing proximal ureteric stones of size ≤2 cm using holmium laser technology. PCNL achieves superior stone clearance but is associated with longer surgery duration and hospital stay. URSL, however, offers advantages in operative time and faster recovery, making it a viable option for appropriate cases.

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