Retrograde Ureteroscopy for Urolithiasis in a North African Tertiary Center: A 4-Year Experience with Exceptionally Low Complication Rates

Retrograde Ureteroscopy for Urolithiasis in a North African Tertiary Center: A 4-Year Experience with Exceptionally Low Complication Rates | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Retrograde Ureteroscopy for Urolithiasis in a North African Tertiary Center: A 4-Year Experience with Exceptionally Low Complication Rates ADIL KBIROU, MOUNIR EL IDRISSI EL JOUHARI, AMINE MOATAZ, MOHAMED DAKIR, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8576107/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Retrograde ureteroscopy has become a first-line treatment for urinary lithiasis, particularly for stones in the upper urinary tract. We present a retrospective analysis of 156 consecutive ureteroscopy procedures performed between January 2020 and December 2023. The primary objective was to evaluate clinical outcomes, treatment efficacy, and safety profile in a North African tertiary center. The cohort consisted of 92 males and 64 females with a mean age of 52.1 years. Notable comorbidities included hypertension in 32 patients (20.5%) and diabetes mellitus in 22 patients (14.1%). Stone characteristics revealed diverse locations, predominantly calyceal (53.9%), with 19 staghorn calculi (12.2%) and 33 multiple calyceal locations (21.8%). Mean stone density was 890.74 ± 180 Hounsfield Units. Preoperative double-J stenting was performed in 96.2% of cases, and systematic antibiotic prophylaxis was administered to all patients. Complete stone fragmentation was achieved in 109 patients, representing a success rate of 69.9%. The postoperative complication rate was exceptionally low at 3.2%, with all five complications classified as Clavien-Dindo grade II acute pyelonephritis managed conservatively with antibiotics. No ureteral strictures, perforations, severe sepsis, or deaths occurred. Mean hospital stay was 1.15 days, with 89.7% of patients discharged within 24 hours. These results demonstrate that ureteroscopy is a safe and effective procedure for urinary lithiasis management in our setting, with outcomes comparable to international standards despite resource limitations in a developing healthcare context. Ureteroscopy Urinary lithiasis Kidney stones Postoperative complications North Africa Endourology Introduction Urinary lithiasis is a frequent pathology worldwide, with estimated prevalence between 1% and 5%, reaching up to 13% in industrialized countries [ 1 , 2 ]. In developing countries, although prevalence is generally lower (0.5 to 1%), stone disease represents a major public health problem due to its morbidity, high recurrence rate (approximately 50% at 10 years), and cost of management [ 3 ]. As throughout North Africa, the prevalence is increasing, probably related to changes in dietary habits and increasing prevalence of metabolic diseases [ 4 ]. Over the past decades, treatment of upper urinary tract stones has been revolutionized by endo-urological techniques, among which retrograde ureteroscopy (URS) occupies a prominent place. According to European Association of Urology (EAU) guidelines, URS is recommended as a first-line treatment option for the majority of ureteral stones and as an effective alternative to extracorporeal lithotripsy (ESWL) for moderate-sized renal stones [ 5 , 6 ]. This minimally invasive procedure offers the advantage of active treatment with high success rates, generally between 70% and 90% according to series [ 6 , 7 , 8 ], low morbidity, and short hospital stay. Technological evolution in recent years, with the advent of small-caliber flexible ureteroscopes, high-power Holmium:YAG lasers, and ureteral access sheaths, has considerably expanded the indications for URS [ 9 ]. Recent innovations, such as suction access sheaths, have demonstrated significant improvement in success rates and reduction in complications [ 10 ]. In the Moroccan and African context, where availability of cutting-edge technologies may be variable, evaluation of local practices is essential. Studies conducted in resource-limited countries have demonstrated the feasibility and efficacy of URS, with results comparable to high-income countries, provided adequate training and protocol standardization [ 11 , 12 ]. The experience of African centers, notably in Dakar, has confirmed that success rates above 85% could be achieved [ 13 ]. Moreover, the relationship between metabolic comorbidities (hypertension, diabetes, obesity) and stone disease is increasingly well documented. Recent cohort studies have demonstrated that metabolic syndrome increases the risk of developing kidney stones by 42% to 100%, with a dose-dependent effect [ 14 ]. This association underscores the importance of a comprehensive management approach, integrating not only stone treatment but also secondary prevention through correction of metabolic risk factors. The objective of this study was to present our single-center experience of urinary lithiasis management by URS, analyzing our results in terms of efficacy and safety, and comparing them with standards reported in recent literature. Materials and Methods Study Design and Population We conducted a retrospective descriptive study including all patients who underwent retrograde ureteroscopy for treatment of upper urinary tract lithiasis at the Urology Department over a four-year period, from January 2020 to December 2023. Inclusion criteria were the presence of one or more symptomatic ureteral or renal stones, confirmed by imaging (ultrasound, plain abdominal radiography, or non-contrast computed tomography). Patients who underwent percutaneous nephrolithotomy or open surgery were excluded from the analysis. This study was approved by the local ethics committee. Informed consent from patients was obtained before data publication, in accordance with the principles of the Declaration of Helsinki. Data Collection Data were collected from computerized medical records and operative registers. The following variables were systematically recorded: Demographic and clinical data: age, sex, body mass index (BMI), relevant medical history (hypertension, diabetes mellitus, obesity, single kidney, history of urological surgery, recurrent urinary tract infections). Stone characteristics: anatomical location (upper, middle or lower calyceal, pelvic, staghorn, lumbar or iliac ureteral, uretero-calyceal), side (right or left), and density in Hounsfield Units (HU) measured on preoperative computed tomography when available. Perioperative data: preparation with preoperative double-J stent (yes/no, drainage duration), antibiotic prophylaxis (antibiotic type, duration), type of anesthesia (general or spinal), operative duration, type of ureteroscope used (semi-rigid or flexible), type of fragmentation energy (Holmium:YAG laser, pneumatic, or combined), use of ureteral access sheath, and procedure success defined by complete fragmentation of the stone into fragments smaller than 2 mm with extraction or predictable spontaneous passage. Postoperative data: length of hospital stay (in days), occurrence of complications classified according to the Clavien-Dindo scale [ 15 ], type of complications (infectious, mechanical, hemorrhagic), need for re-intervention, and duration of postoperative double-J stent maintenance. Definitions Operative success was defined as complete fragmentation of the stone into fragments smaller than 2 mm during the initial procedure, assessed visually by the operator. Incomplete fragmentation corresponded to persistence of fragments larger than 2 mm requiring surveillance or a second procedure. Complications were classified according to the Clavien-Dindo scale: grade I (any deviation from normal without requiring treatment), grade II (requiring medical treatment), grade III (requiring surgical, endoscopic or radiological intervention), grade IV (life-threatening complication requiring intensive care management), and grade V (patient death). Standardized Operative Protocol All patients underwent preoperative evaluation including urine culture with antibiogram if positive, serum creatinine, and recent imaging (preferably computed tomography, or ultrasound and plain abdominal radiography). In case of urinary tract infection, appropriate antibiotic treatment was administered before the procedure. A double-J stent was placed preoperatively in the majority of patients (96.2%), either urgently in case of obstruction with renal impact, or in a planned manner 7 to 14 days before URS to facilitate passive dilation of the ureter. Systematic antibiotic prophylaxis was administered to all patients, generally with a third-generation cephalosporin (ceftriaxone 1 g intravenously) or according to the antibiogram in case of documented urinary tract infection. The procedure was performed under general anesthesia according to patient status and anesthesiologist preferences. A semi-rigid ureteroscope was used first-line for ureteral stones and accessible renal stones, with passage to a flexible ureteroscope for calyceal locations. Fragmentation was performed mainly by Holmium:YAG laser (wavelength 2140 nm, energy 0.6 to 1.2 J, frequency 10 to 20 Hz). A ureteral access sheath was used selectively for large stones or prolonged procedures. At the end of the procedure, a double-J stent was left in place in all patients for 2 to 4 weeks, then removed in outpatient clinic or operating room after radiological control. Patients were hospitalized for a minimum of one night, with discharge authorized in the absence of complications. Statistical Analysis Statistical analysis was performed using SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Quantitative variables were described by their mean and standard deviation in case of normal distribution (verified by the Shapiro-Wilk test), or by their median and extremes in case of non-normal distribution. Qualitative variables were described by their numbers and percentages. Comparisons between groups used the Chi-square test or Fisher's exact test for qualitative variables (according to expected numbers), and Student's t-test or Mann-Whitney test for quantitative variables (according to distribution). Multivariate logistic regression was performed to identify factors independently associated with complications, with calculation of odds ratios (OR) and their 95% confidence intervals. The statistical significance threshold was set at p < 0.05 for all tests. Results Population Characteristics A total of 156 patients were included in the study. Mean age was 52.07 ± 9.49 years, with extremes of 28 to 76 years. Age distribution followed a normal law (Shapiro-Wilk test, p = 0.142). The cohort consisted of 92 men (59.0%) and 64 women (41.0%), giving a sex ratio of 1.44. No significant age difference was observed between sexes (men: 51.3 ± 9.8 years vs women: 53.2 ± 8.9 years; p = 0.138). A significant proportion of patients had comorbidities, particularly metabolic risk factors recognized for stone disease. Hypertension was present in 32 patients (20.5%), diabetes mellitus in 22 patients (14.1%), and the association of both pathologies in 18 patients (11.5%). Four patients (2.6%) had a single kidney (anatomical or functional). Additionally, 32 patients (20.5%) had presented with inaugural acute pyelonephritis that led to emergency double-J stent placement before the planned procedure. Demographic characteristics and history are detailed in Table 1 . Table 1 Patient Demographics and Baseline Characteristics (N = 156) Characteristic Value (n) Percentage (%) Mean age (years) 52.07 ± 9.49 — Sex Male 92 59.0 Female 64 41.0 Sex ratio (M/F) 1.44 — Comorbidities Hypertension 32 20.5 Diabetes mellitus 22 14.1 Hypertension + Diabetes 18 11.5 Single kidney 4 2.6 Stone Characteristics Stone location was diverse, reflecting the variety of indications for retrograde ureteroscopy. Calyceal locations represented the majority of cases (53.9% in total), with a predominance for the lower calyx (25.0%), followed by multiple calyceal locations (21.2%). Staghorn calculi represented 12.2% of the series. Ureteral stones (lumbar and iliac) represented 24.4% of cases. Location details are presented in Table 2 . Stone density could be measured on preoperative computed tomography in 112 patients (71.8%). Mean density was 890.74 ± 180 Hounsfield Units (range: 500 to 1257 HU), with a non-normal distribution (Shapiro-Wilk test, p = 0.018). No significant correlation was found between density and stone location (Kruskal-Wallis test, p = 0.362) or patient age (Pearson correlation coefficient r = 0.026; p = 0.745). These results are consistent with literature data confirming that density depends more on the mineral composition of the stone than on its anatomical location [ 16 ]. Table 2 Stone Characteristics (N = 156) Location Number (n) Percentage (%) Renal locations Lower calyx 39 25.0 Multiple calyceal 33 21.2 Staghorn 19 12.2 Middle calyx 12 7.7 Upper calyx 12 7.7 Ureteral locations Lumbar ureter 19 12.2 Iliac ureter 12 7.7 Mixed locations Uretero-calyceal 10 6.4 Operative Results A double-J stent was placed preoperatively in 150 patients (96.2%), either urgently in case of obstructive acute pyelonephritis (32 cases), or in a planned manner to facilitate the procedure (118 cases). Mean preoperative drainage duration for planned cases was 10.5 ± 3.2 days. Systematic antibiotic prophylaxis was administered to 100% of patients, in accordance with EAU recommendations [ 5 ]. Complete fragmentation was obtained in 109 patients, representing a success rate of 69.9%. For the remaining 47 patients (30.1%), incomplete fragmentation required either surveillance with predictable spontaneous passage of residual fragments (28 cases), or a planned second procedure (19 cases). No significant correlation was found between success rate and age (p = 0.412), sex (p = 0.287), presence of comorbidities (p = 0.521), or stone density (p = 0.362). However, a non-significant trend suggested a lower success rate for staghorn calculi and multiple calyceal locations (p = 0.089). Mean hospital stay was 1.15 days (median: 1 day; range: 1 to 3 days). The majority of patients (89.7%) were discharged the day after surgery (D1), while 10.3% required prolonged hospitalization due to complications or social factors. Operative results are summarized in Table 3 . Table 3 Operative Data and Results (N = 156) Parameter Value Preoperative preparation Preoperative double-J stent 150 (96.2%) Systematic antibiotic prophylaxis 156 (100%) Operative results Complete fragmentation (Success) 109 (69.9%) Incomplete fragmentation 47 (30.1%) — Surveillance (spontaneous passage) 28 (17.9%) — Second procedure required 19 (12.2%) Hospital stay Mean duration (days) 1.15 ± 0.42 Discharge at D1 140 (89.7%) Postoperative Complications The postoperative complication rate was remarkably low at 3.2% (5 patients out of 156). All observed complications were postoperative acute pyelonephritis (Clavien-Dindo grade II), occurring within 48 to 72 hours after the procedure. These infections were successfully treated with intravenous antibiotics adapted according to antibiogram, with a mean treatment duration of 7 days. No patient developed severe sepsis requiring intensive care admission (Clavien-Dindo grade IV). No cases of mechanical complications were recorded in our series: no intraoperative ureteral perforation, no secondary ureteral stricture diagnosed during 3-month follow-up, no hemorrhage requiring transfusion, and no deaths (Clavien-Dindo grade V). This exceptional safety profile testifies to the rigor of our operative protocols and the technical mastery of our team. Multivariate logistic regression analysis was performed to identify factors associated with complications. No significant correlation was found between the occurrence of complications and sex (p = 0.634), age (p = 0.521), presence of comorbidities (p = 0.412), stone location (p = 0.738), or stone density (p = 0.821). Preoperative inaugural acute pyelonephritis tended to be associated with an increased risk of postoperative infectious complications, but this association did not reach statistical significance (OR = 2.34; 95% CI: 0.78–7.12; p = 0.127), probably due to the small number of events. Table 4 summarizes the profile of observed complications. Table 4 Postoperative Complications (N = 156) Complication Type Number (n) Percentage (%) Clavien-Dindo Grade Infectious complications Acute pyelonephritis 5 3.2 II Severe sepsis 0 0 IV Mechanical complications Ureteral perforation 0 0 III Ureteral stricture 0 0 III Hemorrhage requiring transfusion 0 0 II Death 0 0 V Discussion This single-center study of 156 patients treated with retrograde ureteroscopy at University Hospital makes a significant contribution to African endo-urological literature and confirms that this minimally invasive technique can be performed successfully and safely in a resource-limited setting. Our results, characterized by a success rate of 69.9% and a remarkably low complication rate of 3.2%, are consistent with international standards. The complete fragmentation rate of 69.9% observed in our series falls within the lower range of results reported in international literature, which generally varies between 70% and 90% according to studies [ 7 , 17 ]. This variability is explained by several methodological and technical factors. First, the definition of operative success remains heterogeneous in the literature. Some studies define "stone-free" status as absence of residual fragments larger than 4 mm, while others use a 2 mm threshold [ 18 ]. Recent studies emphasize the importance of computed tomography (CT) evaluation with thin slices to confirm absence of residual fragments, this method being markedly superior to plain radiography or ultrasound [ 19 ]. A 2023 study demonstrated that success rates based on plain radiography or ultrasound overestimate stone-free status by 15 to 25% compared to CT [ 20 ]. Second, stone characteristics directly influence success rates. Our series included a significant proportion of complex stones, notably 19 staghorn calculi (12.2%) and 33 multiple calyceal locations (21.2%), which are recognized as factors of increased technical difficulty [ 21 ]. Recent studies have demonstrated that stone size, location (particularly lower pole stones), and total stone burden volume are independent predictors of ureteroscopy success [ 22 , 23 ]. A 2024 meta-analysis confirmed that stones smaller than 6 mm, distally located, and in male patients showed the best success rates [ 24 ]. Another study demonstrated that three-dimensional stone volume measurement was a better predictor of success than simple maximum diameter [ 25 ]. The complexity of our cohort thus partly explains our success rate, which nevertheless remains satisfactory and comparable to real-world practice series [ 26 ]. Third, surgeon experience and learning curve play a determining role. Literature suggests that a urologist must perform between 40 and 60 semi-rigid ureteroscopy procedures to achieve satisfactory competence, and up to 60 to 100 cases for flexible ureteroscopy [ 27 , 28 ]. A 2022 study specified that 40 cases appear sufficient for a surgeon to safely perform semi-rigid ureteroscopy for stones up to 1 cm [ 29 ]. For flexible ureteroscopy, a study of 275 cases demonstrated that a favorable success rate could be achieved from the beginning of learning, but complete mastery required approximately 60 procedures [ 30 ]. The postoperative complication rate of 3.2% observed in our series constitutes a remarkable result and is significantly lower than rates reported in international literature. An exhaustive systematic review by De Coninck et al. (2020), cited over 228 times, analyzed complications of ureteroscopy and reported overall complication rates that can reach 8 to 10% [ 31 ]. A recent 2025 study of the FLEXOR registry (6,684 patients) reported a complication rate of 8.0%, with 1.3% of sepsis requiring intensive care admission [ 32 ]. Another 2025 study confirmed that the retrograde ureteroscopy complication rate is around 10% [ 33 ]. The most frequently described complications in the literature include double-J stent discomfort, ureteral wall injuries (1–4%), stone fragment migration (5–15%), and urinary tract infections (3–10%) [ 31 ]. Serious complications, although rare, include urosepsis (0.5-2%), ureteral perforation requiring intervention (0.5-1%), secondary ureteral stricture (0.5-2%), and exceptionally multi-organ failure or death (< 0.1%) [ 31 , 34 ]. In our cohort, the five observed complications were exclusively postoperative acute pyelonephritis (Clavien-Dindo grade II), all successfully treated with appropriate antibiotic therapy without requiring re-intervention. This exceptional safety profile can be attributed to several organizational and technical factors. First, the quasi-systematic placement of a preoperative double-J stent (96.2% of cases) constitutes an effective prevention strategy [ 5 , 35 ]. Second, systematic antibiotic prophylaxis administered to 100% of patients played a protective role. A 2020 systematic review confirmed that antibiotic prophylaxis significantly reduces the risk of infections, particularly in at-risk patients [ 36 ]. Our postoperative infection rate of 3.2% is significantly lower than the 5–10% rates reported in some series [ 32 ]. One of the most significant aspects of our study is the high prevalence of metabolic comorbidities within our cohort, with 20.5% of hypertensive patients, 14.1% of diabetics, and 11.5% presenting association of both pathologies. These figures are consistent with recent epidemiological data establishing a robust causal link between metabolic syndrome and stone disease. A longitudinal cohort study by Chang et al. (2021) demonstrated that metabolic syndrome increases the risk of developing kidney stones by 42% after adjustment for confounding factors (adjusted OR = 1.42; 95% CI: 1.35–1.49) [ 14 ]. Even more strikingly, this study revealed a dose-dependent effect, with risk doubled in patients presenting all five components of metabolic syndrome. The underlying pathophysiological mechanisms are multiple and complex. Hypertension and diabetes induce changes in urinary pH, favoring crystallization of certain stone types, particularly uric acid stones [ 37 ]. Hyperinsulinemia and insulin resistance alter renal metabolism of calcium and citrate, the latter being a natural inhibitor of crystallization [ 38 ]. Moreover, obesity is associated with increased urinary excretion of oxalate, calcium, and uric acid, all lithogenic factors [ 39 ]. A recent study also demonstrated that diabetes mediates the relationship between cardio-metabolic index and kidney stone formation [ 40 ]. These observations have major clinical implications. The urologist's role is not limited to stone treatment but must extend to secondary prevention through systematic screening of metabolic comorbidities. Lifestyle interventions have demonstrated their effectiveness in reducing stone recurrence risk by 30–50% [ 41 ]. Moreover, optimal glycemic and blood pressure control could have an indirect beneficial effect on preventing new stone formation [ 42 ]. Our results deserve to be compared with data from other African and international centers. A recent systematic review of ureteroscopy outcomes in African countries reported success rates ranging from 65% to 92%, with complication rates between 4% and 15% [ 43 ]. Our complication rate of 3.2% thus positions itself below the African average, demonstrating the feasibility of high-quality endo-urology in resource-limited contexts. Compared to European and North American series, our results are comparable. A large multicenter European study including over 3,000 patients reported a success rate of 78% and a complication rate of 9% [ 44 ]. A recent American study from the Mayo Clinic reported a success rate of 85% with a complication rate of 6% [ 45 ]. Several recent innovations in ureteroscopy could further improve our results. The advent of single-use digital flexible ureteroscopes offers image quality comparable to reusable ureteroscopes while eliminating risks of cross-contamination and repair costs [ 46 ]. Thulium fiber lasers, with their superior efficacy in stone fragmentation compared to Holmium:YAG lasers, allow faster and more complete procedures [ 47 ]. Suction access sheaths with integrated aspiration have demonstrated significant improvement in stone-free rates [ 48 ]. Artificial intelligence for automated stone detection and characterization on CT could optimize treatment planning [ 49 ]. Implementation of enhanced recovery after surgery protocols, patient education through mobile applications [ 50 ], and systematic follow-up strategies [ 51 , 52 , 53 ] could also optimize outcomes. Advanced endoscopic techniques and instrument innovations [ 54 ] continue to evolve and improve patient care. Our study has several limitations. First, its retrospective and single-center design limits generalizability of results. Second, evaluation of operative success was based on intraoperative visual assessment rather than postoperative CT imaging. Third, medium-term follow-up beyond 3 months was not systematically available for all patients. Fourth, the absence of cost-benefit analysis limits evaluation of the economic impact. Finally, information on specific stone composition was not available for all patients. Despite these limitations, our study has important clinical and organizational implications. It demonstrates that high-quality ureteroscopy can be performed safely and effectively in resource-limited contexts, provided rigorous training, protocol standardization, and preventive approach prioritizing patient safety. The high prevalence of metabolic comorbidities in our cohort underscores the need for integrated approach to stone patient management, including not only endoscopic treatment but also metabolic evaluation and multidisciplinary secondary prevention. Several perspectives emerge from our work: implementation of systematic postoperative CT follow-up, development of a prospective database with long-term follow-up, introduction of advanced technologies, and establishment of collaborations with metabolic nephrology and endocrinology departments. Conclusion Retrograde ureteroscopy is a safe and effective procedure for urinary lithiasis treatment within our institution. Our results, with a satisfactory success rate of 69.9% and an exceptionally low complication rate of 3.2%, are comparable to international series, even in resource-limited contexts. These performances underscore the importance of protocol standardization, continuing education, and metabolic prevention to optimize stone patient management. The high prevalence of metabolic comorbidities in our cohort highlights the need for integrated multidisciplinary approach combining endoscopic treatment and secondary prevention. Future studies should focus on long-term outcomes, cost-effectiveness analysis, and evaluation of new technologies to further improve our results. Declarations Author Contribution MK: Study conception, data collection, statistical analysis. MK: Data collection, manuscript writing ,manuscript review. MG: Data collection, manuscript review. 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World J Urol 38(6):1349–1359 Perez Castro E, Osther PJ, Jinga V et al (2014) Differences in ureteroscopic stone treatment and outcomes for distal, mid-, proximal, or multiple ureteral locations: the Clinical Research Office of the Endourological Society ureteroscopy global study. Eur Urol 66(1):102–109 Humphreys MR, Shah OD, Monga M, Chang YH, Krambeck AE, Sur RL (2012) Dusting versus basketing during ureteroscopy—which technique is more efficacious? A prospective multicenter trial from the EDGE Research Consortium. J Urol 199(5):1272–1276 Ventimiglia E, Godínez AJ, Traxer O (2021) Cost-effectiveness of single-use and reusable flexible ureteroscopes: a systematic review. Eur Urol Focus 7(5):1013–1021 Kronenberg P, Traxer O (2019) The truth about Thulium fiber laser: an international update from the recent literature. Int Braz J Urol 45(2):215–224 Traxer O, Wendt-Nordahl G, Sodha H et al (2015) Differences in renal stone treatment and outcomes for patients treated either with or without the support of a ureteral access sheath: The Clinical Research Office of the Endourological Society Ureteroscopy Global Study. World J Urol 33(12):2137–2144 Parakh M, Saiyad SB, Vasekar M et al (2023) Artificial intelligence in the detection and characterization of urinary stones on computed tomography scans: a systematic review. Cent Eur J Urol 76(1):50–58 Ghani KR, Trinh QD, Menon M et al (2013) Text messaging improves ureteric stent symptoms and quality of life: a randomized controlled trial. Eur Urol 64(5):823–830 Torricelli FC, Danilovic A, Vicentini FC et al (2015) Extracorporeal shock wave lithotripsy in the treatment of patients with a solitary kidney: a 20-year experience. Int Braz J Urol 41(1):29–35 Gallagher KM, Hughes J, Dickson AP et al (2014) Flexible ureteroscopy for lower pole stones: an alternative to extracorporeal shockwave lithotripsy and percutaneous nephrolithotomy. Int J Surg 12(Suppl 1):S36–S39 Sahinkanat T, Ekerbicer H, Onal B et al (2008) Evaluation of the effects of relationships among semirigid ureterorenoscopy, access sheath and pneumatic lithotripsy on ureteral tissue. Int Urol Nephrol 40(3):565–570 Tepeler A, Resorlu B, Sahin T et al (2012) Categorization of intraoperative ureteroscopy complications using modified Satava classification system. World J Urol 30(6):851–856 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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10:17:49","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":115706,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8576107/v1/5aae097b1c560d8c8a144850.html"},{"id":107733049,"identity":"f3499e35-bbe1-406d-9874-6f9c7391da6f","added_by":"auto","created_at":"2026-04-24 13:27:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":282261,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8576107/v1/b00695ac-c061-4ee7-94f8-a9f37a1763fa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Retrograde Ureteroscopy for Urolithiasis in a North African Tertiary Center: A 4-Year Experience with Exceptionally Low Complication Rates","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrinary lithiasis is a frequent pathology worldwide, with estimated prevalence between 1% and 5%, reaching up to 13% in industrialized countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In developing countries, although prevalence is generally lower (0.5 to 1%), stone disease represents a major public health problem due to its morbidity, high recurrence rate (approximately 50% at 10 years), and cost of management [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. As throughout North Africa, the prevalence is increasing, probably related to changes in dietary habits and increasing prevalence of metabolic diseases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOver the past decades, treatment of upper urinary tract stones has been revolutionized by endo-urological techniques, among which retrograde ureteroscopy (URS) occupies a prominent place. According to European Association of Urology (EAU) guidelines, URS is recommended as a first-line treatment option for the majority of ureteral stones and as an effective alternative to extracorporeal lithotripsy (ESWL) for moderate-sized renal stones [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This minimally invasive procedure offers the advantage of active treatment with high success rates, generally between 70% and 90% according to series [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], low morbidity, and short hospital stay.\u003c/p\u003e \u003cp\u003eTechnological evolution in recent years, with the advent of small-caliber flexible ureteroscopes, high-power Holmium:YAG lasers, and ureteral access sheaths, has considerably expanded the indications for URS [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Recent innovations, such as suction access sheaths, have demonstrated significant improvement in success rates and reduction in complications [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the Moroccan and African context, where availability of cutting-edge technologies may be variable, evaluation of local practices is essential. Studies conducted in resource-limited countries have demonstrated the feasibility and efficacy of URS, with results comparable to high-income countries, provided adequate training and protocol standardization [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The experience of African centers, notably in Dakar, has confirmed that success rates above 85% could be achieved [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, the relationship between metabolic comorbidities (hypertension, diabetes, obesity) and stone disease is increasingly well documented. Recent cohort studies have demonstrated that metabolic syndrome increases the risk of developing kidney stones by 42% to 100%, with a dose-dependent effect [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This association underscores the importance of a comprehensive management approach, integrating not only stone treatment but also secondary prevention through correction of metabolic risk factors.\u003c/p\u003e \u003cp\u003eThe objective of this study was to present our single-center experience of urinary lithiasis management by URS, analyzing our results in terms of efficacy and safety, and comparing them with standards reported in recent literature.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Population\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective descriptive study including all patients who underwent retrograde ureteroscopy for treatment of upper urinary tract lithiasis at the Urology Department over a four-year period, from January 2020 to December 2023. Inclusion criteria were the presence of one or more symptomatic ureteral or renal stones, confirmed by imaging (ultrasound, plain abdominal radiography, or non-contrast computed tomography). Patients who underwent percutaneous nephrolithotomy or open surgery were excluded from the analysis.\u003c/p\u003e \u003cp\u003e This study was approved by the local ethics committee. Informed consent from patients was obtained before data publication, in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected from computerized medical records and operative registers. The following variables were systematically recorded:\u003c/p\u003e \u003cp\u003eDemographic and clinical data: age, sex, body mass index (BMI), relevant medical history (hypertension, diabetes mellitus, obesity, single kidney, history of urological surgery, recurrent urinary tract infections).\u003c/p\u003e \u003cp\u003eStone characteristics: anatomical location (upper, middle or lower calyceal, pelvic, staghorn, lumbar or iliac ureteral, uretero-calyceal), side (right or left), and density in Hounsfield Units (HU) measured on preoperative computed tomography when available.\u003c/p\u003e \u003cp\u003ePerioperative data: preparation with preoperative double-J stent (yes/no, drainage duration), antibiotic prophylaxis (antibiotic type, duration), type of anesthesia (general or spinal), operative duration, type of ureteroscope used (semi-rigid or flexible), type of fragmentation energy (Holmium:YAG laser, pneumatic, or combined), use of ureteral access sheath, and procedure success defined by complete fragmentation of the stone into fragments smaller than 2 mm with extraction or predictable spontaneous passage.\u003c/p\u003e \u003cp\u003ePostoperative data: length of hospital stay (in days), occurrence of complications classified according to the Clavien-Dindo scale [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], type of complications (infectious, mechanical, hemorrhagic), need for re-intervention, and duration of postoperative double-J stent maintenance.\u003c/p\u003e\n\u003ch3\u003eDefinitions\u003c/h3\u003e\n\u003cp\u003eOperative success was defined as complete fragmentation of the stone into fragments smaller than 2 mm during the initial procedure, assessed visually by the operator. Incomplete fragmentation corresponded to persistence of fragments larger than 2 mm requiring surveillance or a second procedure.\u003c/p\u003e \u003cp\u003eComplications were classified according to the Clavien-Dindo scale: grade I (any deviation from normal without requiring treatment), grade II (requiring medical treatment), grade III (requiring surgical, endoscopic or radiological intervention), grade IV (life-threatening complication requiring intensive care management), and grade V (patient death).\u003c/p\u003e\n\u003ch3\u003eStandardized Operative Protocol\u003c/h3\u003e\n\u003cp\u003eAll patients underwent preoperative evaluation including urine culture with antibiogram if positive, serum creatinine, and recent imaging (preferably computed tomography, or ultrasound and plain abdominal radiography). In case of urinary tract infection, appropriate antibiotic treatment was administered before the procedure. A double-J stent was placed preoperatively in the majority of patients (96.2%), either urgently in case of obstruction with renal impact, or in a planned manner 7 to 14 days before URS to facilitate passive dilation of the ureter. Systematic antibiotic prophylaxis was administered to all patients, generally with a third-generation cephalosporin (ceftriaxone 1 g intravenously) or according to the antibiogram in case of documented urinary tract infection.\u003c/p\u003e \u003cp\u003eThe procedure was performed under general anesthesia according to patient status and anesthesiologist preferences. A semi-rigid ureteroscope was used first-line for ureteral stones and accessible renal stones, with passage to a flexible ureteroscope for calyceal locations. Fragmentation was performed mainly by Holmium:YAG laser (wavelength 2140 nm, energy 0.6 to 1.2 J, frequency 10 to 20 Hz). A ureteral access sheath was used selectively for large stones or prolonged procedures.\u003c/p\u003e \u003cp\u003eAt the end of the procedure, a double-J stent was left in place in all patients for 2 to 4 weeks, then removed in outpatient clinic or operating room after radiological control. Patients were hospitalized for a minimum of one night, with discharge authorized in the absence of complications.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Quantitative variables were described by their mean and standard deviation in case of normal distribution (verified by the Shapiro-Wilk test), or by their median and extremes in case of non-normal distribution. Qualitative variables were described by their numbers and percentages. Comparisons between groups used the Chi-square test or Fisher's exact test for qualitative variables (according to expected numbers), and Student's t-test or Mann-Whitney test for quantitative variables (according to distribution). Multivariate logistic regression was performed to identify factors independently associated with complications, with calculation of odds ratios (OR) and their 95% confidence intervals. The statistical significance threshold was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all tests.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePopulation Characteristics\u003c/h2\u003e \u003cp\u003eA total of 156 patients were included in the study. Mean age was 52.07\u0026thinsp;\u0026plusmn;\u0026thinsp;9.49 years, with extremes of 28 to 76 years. Age distribution followed a normal law (Shapiro-Wilk test, p\u0026thinsp;=\u0026thinsp;0.142). The cohort consisted of 92 men (59.0%) and 64 women (41.0%), giving a sex ratio of 1.44. No significant age difference was observed between sexes (men: 51.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8 years vs women: 53.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9 years; p\u0026thinsp;=\u0026thinsp;0.138).\u003c/p\u003e \u003cp\u003eA significant proportion of patients had comorbidities, particularly metabolic risk factors recognized for stone disease. Hypertension was present in 32 patients (20.5%), diabetes mellitus in 22 patients (14.1%), and the association of both pathologies in 18 patients (11.5%). Four patients (2.6%) had a single kidney (anatomical or functional). Additionally, 32 patients (20.5%) had presented with inaugural acute pyelonephritis that led to emergency double-J stent placement before the planned procedure. Demographic characteristics and history are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Demographics and Baseline Characteristics (N\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.07\u0026thinsp;\u0026plusmn;\u0026thinsp;9.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex ratio (M/F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u0026thinsp;+\u0026thinsp;Diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle kidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStone Characteristics\u003c/h3\u003e\n\u003cp\u003eStone location was diverse, reflecting the variety of indications for retrograde ureteroscopy. Calyceal locations represented the majority of cases (53.9% in total), with a predominance for the lower calyx (25.0%), followed by multiple calyceal locations (21.2%). Staghorn calculi represented 12.2% of the series. Ureteral stones (lumbar and iliac) represented 24.4% of cases. Location details are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eStone density could be measured on preoperative computed tomography in 112 patients (71.8%). Mean density was 890.74\u0026thinsp;\u0026plusmn;\u0026thinsp;180 Hounsfield Units (range: 500 to 1257 HU), with a non-normal distribution (Shapiro-Wilk test, p\u0026thinsp;=\u0026thinsp;0.018). No significant correlation was found between density and stone location (Kruskal-Wallis test, p\u0026thinsp;=\u0026thinsp;0.362) or patient age (Pearson correlation coefficient r\u0026thinsp;=\u0026thinsp;0.026; p\u0026thinsp;=\u0026thinsp;0.745). These results are consistent with literature data confirming that density depends more on the mineral composition of the stone than on its anatomical location [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStone Characteristics (N\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal locations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower calyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple calyceal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaghorn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle calyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper calyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUreteral locations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar ureter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIliac ureter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed locations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUretero-calyceal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOperative Results\u003c/h2\u003e \u003cp\u003eA double-J stent was placed preoperatively in 150 patients (96.2%), either urgently in case of obstructive acute pyelonephritis (32 cases), or in a planned manner to facilitate the procedure (118 cases). Mean preoperative drainage duration for planned cases was 10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 days. Systematic antibiotic prophylaxis was administered to 100% of patients, in accordance with EAU recommendations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eComplete fragmentation was obtained in 109 patients, representing a success rate of 69.9%. For the remaining 47 patients (30.1%), incomplete fragmentation required either surveillance with predictable spontaneous passage of residual fragments (28 cases), or a planned second procedure (19 cases). No significant correlation was found between success rate and age (p\u0026thinsp;=\u0026thinsp;0.412), sex (p\u0026thinsp;=\u0026thinsp;0.287), presence of comorbidities (p\u0026thinsp;=\u0026thinsp;0.521), or stone density (p\u0026thinsp;=\u0026thinsp;0.362). However, a non-significant trend suggested a lower success rate for staghorn calculi and multiple calyceal locations (p\u0026thinsp;=\u0026thinsp;0.089).\u003c/p\u003e \u003cp\u003eMean hospital stay was 1.15 days (median: 1 day; range: 1 to 3 days). The majority of patients (89.7%) were discharged the day after surgery (D1), while 10.3% required prolonged hospitalization due to complications or social factors. Operative results are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative Data and Results (N\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative preparation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative double-J stent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (96.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystematic antibiotic prophylaxis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative results\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete fragmentation (Success)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109 (69.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncomplete fragmentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (30.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026mdash; Surveillance (spontaneous passage)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (17.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026mdash; Second procedure required\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean duration (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarge at D1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (89.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Complications\u003c/h2\u003e \u003cp\u003eThe postoperative complication rate was remarkably low at 3.2% (5 patients out of 156). All observed complications were postoperative acute pyelonephritis (Clavien-Dindo grade II), occurring within 48 to 72 hours after the procedure. These infections were successfully treated with intravenous antibiotics adapted according to antibiogram, with a mean treatment duration of 7 days. No patient developed severe sepsis requiring intensive care admission (Clavien-Dindo grade IV).\u003c/p\u003e \u003cp\u003eNo cases of mechanical complications were recorded in our series: no intraoperative ureteral perforation, no secondary ureteral stricture diagnosed during 3-month follow-up, no hemorrhage requiring transfusion, and no deaths (Clavien-Dindo grade V). This exceptional safety profile testifies to the rigor of our operative protocols and the technical mastery of our team.\u003c/p\u003e \u003cp\u003eMultivariate logistic regression analysis was performed to identify factors associated with complications. No significant correlation was found between the occurrence of complications and sex (p\u0026thinsp;=\u0026thinsp;0.634), age (p\u0026thinsp;=\u0026thinsp;0.521), presence of comorbidities (p\u0026thinsp;=\u0026thinsp;0.412), stone location (p\u0026thinsp;=\u0026thinsp;0.738), or stone density (p\u0026thinsp;=\u0026thinsp;0.821). Preoperative inaugural acute pyelonephritis tended to be associated with an increased risk of postoperative infectious complications, but this association did not reach statistical significance (OR\u0026thinsp;=\u0026thinsp;2.34; 95% CI: 0.78\u0026ndash;7.12; p\u0026thinsp;=\u0026thinsp;0.127), probably due to the small number of events.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the profile of observed complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative Complications (N\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClavien-Dindo Grade\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfectious complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute pyelonephritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUreteral perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUreteral stricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemorrhage requiring transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis single-center study of 156 patients treated with retrograde ureteroscopy at University Hospital makes a significant contribution to African endo-urological literature and confirms that this minimally invasive technique can be performed successfully and safely in a resource-limited setting. Our results, characterized by a success rate of 69.9% and a remarkably low complication rate of 3.2%, are consistent with international standards.\u003c/p\u003e \u003cp\u003eThe complete fragmentation rate of 69.9% observed in our series falls within the lower range of results reported in international literature, which generally varies between 70% and 90% according to studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This variability is explained by several methodological and technical factors. First, the definition of operative success remains heterogeneous in the literature. Some studies define \"stone-free\" status as absence of residual fragments larger than 4 mm, while others use a 2 mm threshold [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Recent studies emphasize the importance of computed tomography (CT) evaluation with thin slices to confirm absence of residual fragments, this method being markedly superior to plain radiography or ultrasound [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A 2023 study demonstrated that success rates based on plain radiography or ultrasound overestimate stone-free status by 15 to 25% compared to CT [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSecond, stone characteristics directly influence success rates. Our series included a significant proportion of complex stones, notably 19 staghorn calculi (12.2%) and 33 multiple calyceal locations (21.2%), which are recognized as factors of increased technical difficulty [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Recent studies have demonstrated that stone size, location (particularly lower pole stones), and total stone burden volume are independent predictors of ureteroscopy success [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A 2024 meta-analysis confirmed that stones smaller than 6 mm, distally located, and in male patients showed the best success rates [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Another study demonstrated that three-dimensional stone volume measurement was a better predictor of success than simple maximum diameter [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The complexity of our cohort thus partly explains our success rate, which nevertheless remains satisfactory and comparable to real-world practice series [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThird, surgeon experience and learning curve play a determining role. Literature suggests that a urologist must perform between 40 and 60 semi-rigid ureteroscopy procedures to achieve satisfactory competence, and up to 60 to 100 cases for flexible ureteroscopy [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. A 2022 study specified that 40 cases appear sufficient for a surgeon to safely perform semi-rigid ureteroscopy for stones up to 1 cm [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. For flexible ureteroscopy, a study of 275 cases demonstrated that a favorable success rate could be achieved from the beginning of learning, but complete mastery required approximately 60 procedures [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe postoperative complication rate of 3.2% observed in our series constitutes a remarkable result and is significantly lower than rates reported in international literature. An exhaustive systematic review by De Coninck et al. (2020), cited over 228 times, analyzed complications of ureteroscopy and reported overall complication rates that can reach 8 to 10% [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. A recent 2025 study of the FLEXOR registry (6,684 patients) reported a complication rate of 8.0%, with 1.3% of sepsis requiring intensive care admission [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Another 2025 study confirmed that the retrograde ureteroscopy complication rate is around 10% [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The most frequently described complications in the literature include double-J stent discomfort, ureteral wall injuries (1\u0026ndash;4%), stone fragment migration (5\u0026ndash;15%), and urinary tract infections (3\u0026ndash;10%) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Serious complications, although rare, include urosepsis (0.5-2%), ureteral perforation requiring intervention (0.5-1%), secondary ureteral stricture (0.5-2%), and exceptionally multi-organ failure or death (\u0026lt;\u0026thinsp;0.1%) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our cohort, the five observed complications were exclusively postoperative acute pyelonephritis (Clavien-Dindo grade II), all successfully treated with appropriate antibiotic therapy without requiring re-intervention. This exceptional safety profile can be attributed to several organizational and technical factors. First, the quasi-systematic placement of a preoperative double-J stent (96.2% of cases) constitutes an effective prevention strategy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Second, systematic antibiotic prophylaxis administered to 100% of patients played a protective role. A 2020 systematic review confirmed that antibiotic prophylaxis significantly reduces the risk of infections, particularly in at-risk patients [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Our postoperative infection rate of 3.2% is significantly lower than the 5\u0026ndash;10% rates reported in some series [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the most significant aspects of our study is the high prevalence of metabolic comorbidities within our cohort, with 20.5% of hypertensive patients, 14.1% of diabetics, and 11.5% presenting association of both pathologies. These figures are consistent with recent epidemiological data establishing a robust causal link between metabolic syndrome and stone disease. A longitudinal cohort study by Chang et al. (2021) demonstrated that metabolic syndrome increases the risk of developing kidney stones by 42% after adjustment for confounding factors (adjusted OR\u0026thinsp;=\u0026thinsp;1.42; 95% CI: 1.35\u0026ndash;1.49) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Even more strikingly, this study revealed a dose-dependent effect, with risk doubled in patients presenting all five components of metabolic syndrome.\u003c/p\u003e \u003cp\u003eThe underlying pathophysiological mechanisms are multiple and complex. Hypertension and diabetes induce changes in urinary pH, favoring crystallization of certain stone types, particularly uric acid stones [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Hyperinsulinemia and insulin resistance alter renal metabolism of calcium and citrate, the latter being a natural inhibitor of crystallization [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Moreover, obesity is associated with increased urinary excretion of oxalate, calcium, and uric acid, all lithogenic factors [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. A recent study also demonstrated that diabetes mediates the relationship between cardio-metabolic index and kidney stone formation [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. These observations have major clinical implications. The urologist's role is not limited to stone treatment but must extend to secondary prevention through systematic screening of metabolic comorbidities. Lifestyle interventions have demonstrated their effectiveness in reducing stone recurrence risk by 30\u0026ndash;50% [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Moreover, optimal glycemic and blood pressure control could have an indirect beneficial effect on preventing new stone formation [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur results deserve to be compared with data from other African and international centers. A recent systematic review of ureteroscopy outcomes in African countries reported success rates ranging from 65% to 92%, with complication rates between 4% and 15% [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Our complication rate of 3.2% thus positions itself below the African average, demonstrating the feasibility of high-quality endo-urology in resource-limited contexts. Compared to European and North American series, our results are comparable. A large multicenter European study including over 3,000 patients reported a success rate of 78% and a complication rate of 9% [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. A recent American study from the Mayo Clinic reported a success rate of 85% with a complication rate of 6% [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral recent innovations in ureteroscopy could further improve our results. The advent of single-use digital flexible ureteroscopes offers image quality comparable to reusable ureteroscopes while eliminating risks of cross-contamination and repair costs [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Thulium fiber lasers, with their superior efficacy in stone fragmentation compared to Holmium:YAG lasers, allow faster and more complete procedures [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Suction access sheaths with integrated aspiration have demonstrated significant improvement in stone-free rates [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Artificial intelligence for automated stone detection and characterization on CT could optimize treatment planning [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Implementation of enhanced recovery after surgery protocols, patient education through mobile applications [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], and systematic follow-up strategies [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] could also optimize outcomes. Advanced endoscopic techniques and instrument innovations [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] continue to evolve and improve patient care.\u003c/p\u003e \u003cp\u003eOur study has several limitations. First, its retrospective and single-center design limits generalizability of results. Second, evaluation of operative success was based on intraoperative visual assessment rather than postoperative CT imaging. Third, medium-term follow-up beyond 3 months was not systematically available for all patients. Fourth, the absence of cost-benefit analysis limits evaluation of the economic impact. Finally, information on specific stone composition was not available for all patients.\u003c/p\u003e \u003cp\u003eDespite these limitations, our study has important clinical and organizational implications. It demonstrates that high-quality ureteroscopy can be performed safely and effectively in resource-limited contexts, provided rigorous training, protocol standardization, and preventive approach prioritizing patient safety. The high prevalence of metabolic comorbidities in our cohort underscores the need for integrated approach to stone patient management, including not only endoscopic treatment but also metabolic evaluation and multidisciplinary secondary prevention. Several perspectives emerge from our work: implementation of systematic postoperative CT follow-up, development of a prospective database with long-term follow-up, introduction of advanced technologies, and establishment of collaborations with metabolic nephrology and endocrinology departments.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRetrograde ureteroscopy is a safe and effective procedure for urinary lithiasis treatment within our institution. Our results, with a satisfactory success rate of 69.9% and an exceptionally low complication rate of 3.2%, are comparable to international series, even in resource-limited contexts. These performances underscore the importance of protocol standardization, continuing education, and metabolic prevention to optimize stone patient management. The high prevalence of metabolic comorbidities in our cohort highlights the need for integrated multidisciplinary approach combining endoscopic treatment and secondary prevention. Future studies should focus on long-term outcomes, cost-effectiveness analysis, and evaluation of new technologies to further improve our results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMK: Study conception, data collection, statistical analysis. MK: Data collection, manuscript writing ,manuscript review. MG: Data collection, manuscript review. AJ: Manuscript review, supervision. AA: Manuscript review, supervision. RA: Study supervision, critical manuscript revision, final approval.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRomero V, Akpinar H, Assimos DG (2010) Kidney stones: a global picture of prevalence, incidence, and associated risk factors. Rev Urol 12(2\u0026ndash;3):e86\u0026ndash;96\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScales CD Jr, Smith AC, Hanley JM, Saigal CS (2012) Prevalence of kidney stones in the United States. 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World J Urol 30(6):851\u0026ndash;856\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ureteroscopy, Urinary lithiasis, Kidney stones, Postoperative complications, North Africa, Endourology","lastPublishedDoi":"10.21203/rs.3.rs-8576107/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8576107/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eRetrograde ureteroscopy has become a first-line treatment for urinary lithiasis, particularly for stones in the upper urinary tract. We present a retrospective analysis of 156 consecutive ureteroscopy procedures performed between January 2020 and December 2023. The primary objective was to evaluate clinical outcomes, treatment efficacy, and safety profile in a North African tertiary center. The cohort consisted of 92 males and 64 females with a mean age of 52.1 years. Notable comorbidities included hypertension in 32 patients (20.5%) and diabetes mellitus in 22 patients (14.1%). Stone characteristics revealed diverse locations, predominantly calyceal (53.9%), with 19 staghorn calculi (12.2%) and 33 multiple calyceal locations (21.8%). Mean stone density was 890.74\u0026thinsp;\u0026plusmn;\u0026thinsp;180 Hounsfield Units. Preoperative double-J stenting was performed in 96.2% of cases, and systematic antibiotic prophylaxis was administered to all patients. Complete stone fragmentation was achieved in 109 patients, representing a success rate of 69.9%. The postoperative complication rate was exceptionally low at 3.2%, with all five complications classified as Clavien-Dindo grade II acute pyelonephritis managed conservatively with antibiotics. No ureteral strictures, perforations, severe sepsis, or deaths occurred. Mean hospital stay was 1.15 days, with 89.7% of patients discharged within 24 hours. These results demonstrate that ureteroscopy is a safe and effective procedure for urinary lithiasis management in our setting, with outcomes comparable to international standards despite resource limitations in a developing healthcare context.\u003c/p\u003e","manuscriptTitle":"Retrograde Ureteroscopy for Urolithiasis in a North African Tertiary Center: A 4-Year Experience with Exceptionally Low Complication Rates","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 10:17:40","doi":"10.21203/rs.3.rs-8576107/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"52422490-9218-43fa-84c0-334fe8181b49","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T13:26:54+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 10:17:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8576107","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8576107","identity":"rs-8576107","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}