Second in situ extracorporeal shock wave lithotripsy in not disintegrated ureteral stones is preferred to retrograde manipulation.

In this study we tried to determine the optimal treatment of upper ureteral stones which are not disintegrated by the first extracorporeal shock wave lithotripsy (ESWL) and to analyze the cost-benefit ratio of retrograde manipulation into the renal pelvis. 180 patients with an upper ureteral stone were treated by ESWL in situ. 40 patients needed a retreatment and were randomized for retrograde manipulation before ESWL or ESWL in situ without a prior manipulation. In both the in situ group and in the push-and-smash group, the stone-free rate was 75%. In stones < 8 mm, the disintegration rate was higher after retrograde manipulation into the renal pelvis and inserting a DJ catheter. In conclusion, ESWL in situ is the optimal treatment for all patients with upper ureteral stones. We reserve retrograde manipulation before a second ESWL for stones < 8 mm. Routinely employed auxiliary procedures such as placement of a DJ catheter increase the costs significantly, without improving the results.