In general, single-session treatment with ureteroscopy had much higher and more consistent stone-free rates (86.6–97.5 %) than SWL (35–77.5 %). Efficiency quotients (EQ) were significantly worse for SWL in three of five studies that included this measure. Complication rates tended to be higher for URS, however the overall incidence was low.

Amongst the studies that noted quality of life, the findings were variable. Patients with SWL presented more often to the ER and office with renal colic, whereas URS patients sought care more frequently for stent-related lower urinary tract symptoms.

Kumar et al. [47] compared semi-rigid URS with holmium laser to SWL with a third-generation lithotripter [47]. Mean stone size was 12.5 and 12.3 cm for URS and SWL patients, respectively. While no significant difference was noted in stone-free rates, a significantly higher re-treatment rate was required for SWL (61.1 % vs. 11.1 %, p < 0.0001, average 1.6 SWL sessions). As expected, the EQ was higher for URS, especially for stones larger than 10 mm (83.4 vs 46.4, p = 0.01). The overall complication rate was higher for URS (11.1 % vs. 6.6 %), but this difference was not statistically significant. There was no difference in the incidence of UTI or severe pain amongst the two groups.

Although a retrospective analysis, Cui et al. [48] provide an interesting comparison between SWL with a third-generation device and URS with holmium laser [48]. Mean stone size was approximately 10 mm for each group. Stone-free rates were ultimately similar (92.5 % SWL vs. 97.5 % URS) although single session SFR for SWL was 77.5 %. URS patients had significantly more lower urinary tract symptoms. URS costs were greater, largely because of its average 2-day hospitalization. Patient satisfaction scores were similar for the two modalities.

Percutaneous antegrade ureteroscopy is an alternative approach for proximal ureteral stones. Basiri et al. [49] randomized 150 patients to URS, PCNL or laparoscopic ureterolithotomy [49]. There was no significant difference in stone-free rates between URS and PCNL (76 % vs. 86 %, p = 0.2). Eighteen percent of patients that had PCNL had persistent urinary leak >3 days beyond surgery. The stone-free rate for the laparoscopic approach was 90 %, however two patients required conversion to open surgery and eight patients (18 %) had a persistent urinary leakage.

Sun et al. [50] compared retrograde URS with “mini” percutaneous antegrade ureteroscopy for impacted proximal stones [50]. Antegrade URS was performed with an 8Fr or 9.5Fr semi-rigid scope through a small access channel. The average stone size was 14.6 mm. A higher stone-free rate was noted for the antegrade approach (100 % vs 86.4 %, p = 0.02), however operative times, hospital stay, and return to normal activities was significantly greater for this group. Minimally-invasive methods to perform antegrade stone treatment for this challenging patient population continue to be investigated [51, 52].

Matlaga et al. conducted a systematic review in 2012 of randomized controlled trials [53]. This study deliberately separated studies that utilized the HM3 lithotripter and subsequent generation devices due to the noted differences in results [54]. Relevant findings for proximal stones included a greater probability of being stone free with URS than SWL with HM3 (RR 1.35) and other lithotripters (RR 1.15). The chance of re-treatment, notably, was much higher with HM3 and other SWL devices (RR 0.14 and RR 0.08, respectively, compared with URS). URS had a higher likelihood of complications than either SWL modality.