Urolithiasis remains a prevalent urological condition worldwide, with ureteric calculi accounting for a significant proportion of stone-related emergencies. The upper ureter, due to its narrow anatomical structure, is particularly susceptible to obstruction by calculi, resulting in acute pain, hydronephrosis, and potential renal dysfunction if not managed promptly.

With the advent of endourological techniques, the treatment of ureteric stones has evolved significantly, minimizing the need for open surgical procedures. Among the intracorporeal lithotripsy methods employed during ureteroscopy, pneumatic lithotripsy and holmium:YAG laser lithotripsy are most commonly used. Pneumatic lithotripsy utilizes mechanical energy to fragment the stone, whereas the holmium laser delivers laser energy to disintegrate the stone through a combination of photothermal and photomechanical effects (1–3).

Although both modalities are effective, key differences exist in terms of fragmentation efficiency, operative duration, complication rates, and risk of stone migration. Pneumatic lithotripsy is more widely available and cost-effective, making it a practical choice in many clinical settings, particularly in resource-limited environments (2,4). However, its major drawback is a higher rate of proximal stone migration, which can reduce overall success rates and necessitate additional interventions (5). On the other hand, holmium:YAG laser lithotripsy offers greater precision, a higher stone-free rate, and lower rates of migration, albeit at a higher equipment and maintenance cost (1,3,6).

Given the ongoing debate over the optimal choice for upper ureteric calculi, especially in resource-constrained settings, a direct comparison of these two modalities is warranted. This study aims to evaluate and compare the efficacy, safety, and clinical outcomes of pneumatic versus holmium laser lithotripsy in the management of upper ureteric stones, thereby guiding evidence-based selection of the appropriate modality for patient care.

Study Design and Setting

This was a prospective, comparative study conducted in the Department of Urology, Kurnool Medical College and Government General Hospital, Kurnool, over a period of 12 months from January 2021 to December 2021. The study aimed to evaluate and compare the clinical outcomes of pneumatic versus holmium:YAG laser lithotripsy for upper ureteric calculi.

Study Population

A total of 100 patients diagnosed with upper ureteric stones were enrolled and randomized into two groups:

Group A (n = 50): Underwent ureteroscopic pneumatic lithotripsy

Group B (n = 50): Underwent ureteroscopic holmium:YAG laser lithotripsy

Inclusion Criteria

Age between 18 and 65 years

Solitary upper ureteric calculus (7–15 mm in size)

Radio-opaque stones confirmed on NCCT-KUB

Normal renal function

Informed written consent obtained

Exclusion Criteria

Bilateral or multiple stones

Active urinary tract infection

Coagulopathy or bleeding disorders

Congenital or acquired ureteral anomalies

Pregnancy

Prior ureteric surgery on the same side

Preoperative Evaluation

All patients underwent a detailed history and clinical examination followed by routine investigations, including:

Hemogram, renal function tests, and coagulation profile

Urinalysis and urine culture

Imaging with non-contrast CT KUB

Surgical Procedure

Under spinal or general anesthesia, semirigid ureteroscopy was performed using a 6/7.5 Fr ureteroscope.

In Group A, stone fragmentation was performed using a pneumatic lithotripter.

In Group B, fragmentation was achieved using a holmium:YAG laser (settings: 0.8–1.2 J, 10–15 Hz).
A double-J (DJ) stent was placed in most cases based on intraoperative findings and surgeon discretion.

Postoperative Care and Follow-Up

Patients were monitored postoperatively for pain, hematuria, fever, and other complications.
Follow-up was done at 4 weeks postoperatively with ultrasound KUB and X-ray KUB or NCCT to evaluate:

Stone clearance

Residual fragments >3 mm

DJ stent status and removal

Outcome Measures

The following parameters were assessed and compared between groups:

Operative time

Stone-free rate after a single session

Stone migration rate

Postoperative complications

Hospital stay duration

Need for ancillary procedures

Statistical Analysis

All data were compiled using Microsoft Excel and analyzed using SPSS version 22.0. Categorical variables were compared using the Chi-square test, and continuous variables using the student’s t-test. A p-value < 0.05 was considered statistically significant.

Ethical Considerations

The study was approved by the Institutional Ethics Committee of Kurnool Medical College. Informed written consent was obtained from all participants prior to inclusion, ensuring confidentiality and adherence to ethical guidelines.

A total of 100 patients with upper ureteric calculi were included in the study and were equally divided into two groups: Group A (Pneumatic lithotripsy, n = 50) and Group B (Holmium laser lithotripsy, n = 50). Both groups were comparable in terms of baseline demographic and stone-related characteristics. The mean age was 42.3 ± 10.1 years in the pneumatic group and 41.7 ± 9.8 years in the laser group (p = 0.74). The male-to-female ratio, mean stone size, and side of stone involvement were similar between groups with no statistically significant differences (Table 1).

Table 1: Demographic and Stone Characteristics

Operative parameters revealed that the mean operative time was significantly shorter in the holmium laser group (31.2 ± 4.9 minutes) compared to the pneumatic group (36.4 ± 5.2 minutes) (p < 0.001). Stone migration during the procedure occurred in 12% of patients in the pneumatic group, whereas only 2% in the laser group experienced migration, showing a statistically significant difference (p = 0.03). Although auxiliary procedures were needed more frequently in the pneumatic group (10%) than the laser group (4%), this difference was not statistically significant (p = 0.24) (Table 2).

Table 2: Intraoperative Parameters

Figure 1. Comparision of Intraoperative Parameters

Postoperative outcomes favored the holmium laser group. The stone-free rate after a single session was significantly higher in the laser group (96%) compared to the pneumatic group (84%) (p = 0.04). Additionally, the mean duration of hospital stay was shorter in the laser group (1.4 ± 0.3 days) compared to the pneumatic group (1.8 ± 0.4 days) (p < 0.01). The incidence of minor complications was similar between the groups and did not reach statistical significance (Table 3).

Table 3: Postoperative Outcomes

Figure 2. Comparision of Postoperative Outcomes

At 4-week follow-up, residual stone fragments >3 mm were identified in 16% of patients in the pneumatic group and 4% in the laser group (p = 0.04). The requirement for a second procedure was higher in the pneumatic group (8%) than in the laser group (2%), though not statistically significant (p = 0.17). DJ stents were required beyond 4 weeks in 6% of pneumatic and 2% of laser group patients (p = 0.30) (Table 4).

Table 4: Follow-Up Outcomes at 4 Weeks

Figure 3. Comparison of Follow -Up Outcomes at 4 Weeks

The present study compared the efficacy and safety of pneumatic lithotripsy and holmium:YAG laser lithotripsy in the management of upper ureteric calculi. Our results indicate that holmium laser lithotripsy offers superior clinical outcomes, including a higher stone-free rate, shorter operative time, and reduced incidence of stone migration—findings that are consistent with multiple previous studies in the literature (7–9).

In our study, the stone-free rate after a single session was 96% in the holmium group versus 84% in the pneumatic group, reflecting the laser’s ability to disintegrate stones into finer particles that facilitate easier passage or retrieval. Similar outcomes have been reported by Degirmenci et al. and Maghsoudi et al., who found significantly better clearance rates with holmium laser lithotripsy, especially for impacted ureteric stones (7,9).

The mean operative time was significantly lower in the holmium group, suggesting enhanced procedural efficiency. This is in line with the findings of Kızılay et al. and Razzaghi et al., who attributed reduced operative durations to continuous and precise laser fragmentation with minimal retropulsion compared to the stop-start mechanism of pneumatic devices (8,10).

Stone migration, a key limitation of pneumatic lithotripsy, occurred in 12% of cases in our pneumatic group versus only 2% in the holmium group. This difference has been well-documented in prior research, with Chunlin et al. and Tipu et al. highlighting the laser’s advantage in minimizing proximal migration through controlled energy delivery and reduced mechanical impact (11,12).

Although the complication rates in both groups were low and statistically insignificant, the holmium laser group demonstrated a shorter postoperative hospital stay. This may be attributed to less mucosal trauma, faster recovery, and better intraoperative outcomes, as also observed in previous comparative studies (10,12). Additionally, follow-up at 4 weeks revealed fewer residual fragments and a reduced need for ancillary procedures in the holmium group, reinforcing its long-term effectiveness.
Despite these advantages, pneumatic lithotripsy remains a viable and practical option, particularly in settings with limited access to laser equipment. It continues to offer acceptable efficacy, especially where cost constraints are a concern (8,12).

Our study is limited by its single-center design and relatively short follow-up period. Long-term outcomes, cost analysis, and patient-reported satisfaction were not assessed but warrant further investigation.

This comparative study demonstrates that holmium:YAG laser lithotripsy is a more effective and safer modality than pneumatic lithotripsy for the management of upper ureteric calculi. It offers significantly higher stone-free rates, shorter operative time, reduced stone migration, and fewer residual fragments at follow-up. Although both techniques were associated with minimal complications, the holmium laser group also benefited from a shorter hospital stay and decreased need for ancillary procedures. While pneumatic lithotripsy remains a cost-effective option in resource-constrained settings, holmium laser lithotripsy should be preferred where available, due to its superior outcomes and procedural efficiency in treating upper ureteric stones.

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