electrohydraulic lithotripsy of ureteral calculi. J. Urol., 133:767, 1985.

9. Dretler, S. P.: In situ ESWL vs. ureteroscopy: the case for uret-eroscopy. J. Endourol., 3: 301, 1989.

10. Morse, R. M. and Resnick M. I.: Ureteral calculi: natural historyand treatment in an era of advanced technology. J. Urol., 145:263, 1991.

11. Bierkens, A. F., Hendrikx, A. J., De la Rosette, J. J., Stultiens,G. N., Beerlage, H. P., Arends, A. J. and Debruyne, F. M.:Treatment of mid- and lower ureteric calculi: extracorporealshock wave lithotripsy vs. laser ureteroscopy: a comparison ofcosts, morbidity and effectiveness. Brit. J. Urol., 81: 31, 1998.

12. Becht, E., Moll, V., Neisius, D. and Ziegler, M.: Treatment ofprevesical ureteral calculi by extracorporal shock wave litho-tripsy. J. Urol., 139: 916, 1988.

13. Stackl, W. and Marberger, M.: Late sequelae of the managementof ureteral calculi with the ureterorenoscope. J. Urol., 136:386, 1986.

14. Zisman, A., Siegel, Y. I. and Lindner, A.: Ureteroscopy for uret-erolithiasis with sedation only. Eur. Urol., 27: 151, 1995.

15. Miroglu, C. and Saporta, L.: Transurethral ureteroscopy: is localanesthesia with intravenous sedation sufficiently effective andsafe? Eur. Urol., 31: 36, 1997.

EDITORIAL COMMENT

This outstanding study is the kind that should be performed insituations when competing treatments are advocated for specificclinical circumstances. The authors make a number of points worthemphasizing in discussions about the pros and cons of ureteroscopyor shock wave lithotripsy for distal ureteral stones. The proceduretime for ureteroscopy was only 18.8 minutes for stones less than 5mm. and 28 minutes for larger stones. This finding reflects the factthat small stones can be readily extracted and, even with largerfragments, once the stone is broken into smaller pieces extraction isusually quick. Furthermore, the fluoroscopic imaging time was farless with ureteroscopy than shock wave lithotripsy and, while thetotal fluoroscopy time was not great, 48 seconds (mean time) is

clearly superior to the 5 minutes needed for ESWL. Another positivefactor in the study design was the delay of treatment for 3 weeks afterdiagnosis to optimize chances for spontaneous passage of stones.

This is one of the few studies that I can recall when the issue ofpatient satisfaction was addressed, and it is interesting thatthose treated with ureteroscopy were uniformly satisfied while anumber treated with ESWL were not. The source of this dissatisfac-tion has been related to what I have always considered to be a greatadvantage of ureteroscopy, which is that the patient achieves animmediate or nearly immediate stone-free state, which cannotbe guaranteed for shock wave lithotripsy. A further advantage ofureteroscopy is that fewer followup examinations were required todetermine the ultimate outcome, resulting in savings in cost as wellas physician and patient time.

Routine use of a stent after ureteroscopy has been the majordisadvantage of ureteroscopic stone removal. Few patients are en-amored with the stent and most complain of urgency, frequency anddiscomfort, although most readily tolerate this for the 2 days or sothat the stent has been in place. In a recent prospective studypatients undergoing ureteroscopy without dilation for small ureteralstones were randomized to stent versus no stent and at the time ofthe report the latter were no more symptomatic than the former.1 Itmay be possible to perform ureteroscopy without routine stent place-ment routinely, at least in certain patients. Ultimately, the choice oftreatment is a function of patient attitudes to each procedure, itsrisks and its hazards.

Joseph W. SeguraDepartment of UrologyMayo ClinicRochester, Minnesota

1. Wollin, T. A., Nott, L., Denstedt, J. D., Honey, R. J., Incze, P. andLuymes, J.: Early results of a prospective randomized con-trolled trial comparing stented versus non-stented uretero-scopic lithotripsy. J. Urol., part 2, 161: 371, abstract 1438,1999.

EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY VERSUS URETEROSCOPY FOR DISTAL URETERAL STONES1912