In recent years, minimally invasive percutaneous nephrolithotomy (MPCNL) has been widely used in the management of smaller renal stones or upper ureteral stones. This method only expands the puncture channel to F14 or F16 and replaces nephroscopy with ureteroscopy, which significantly reduces the risk of intraoperative hemorrhage and renal cortical tear while retaining the advantages of traditional PCNL. However, there are disadvantages such as lower efficiency in handling larger stones and easy residual stones. From February 2003 to May 2006, 22 patients with large stones (>1.0 cm) in the upper ureter were treated with the F20.8 percutaneous nephrolithoscope combined with the third-generation pneumatic ballistic and ultrasonic lithotripsy system produced by EMS, with satisfactory results. 1 Data and methods 1.1 General data 22 cases, 15 males and 7 females, aged 33-71 years old, average 49 years old, were diagnosed by ultrasound, intravenous pyelogram or CT before surgery. The stones were located in the left ureter in 12 cases and in the right ureter in 10 cases; 7 cases were combined with kidney stones; 13 cases failed to be treated by extracorporeal shock wave lithotripsy (ESWL); 3 cases failed to be treated by transurethral ureteroscopy (URL); the stones were 1.0cm-2.5cm in length, with an average of 1.6cm. 1.2 Treatment Methods Preoperative urine bacterial culture was routinely performed, and those with combined urinary tract infection were treated with antibiotics. Antibiotics were used to treat the combined urinary tract infection. The patient was firstly placed in a lithotomy position, and a 5F ureteral catheter was inserted into the ureter of the affected side under cystoscopy to the renal pelvis; if it was difficult to place the catheter under cystoscopy, the catheter could be made to cross the stone and reach the renal pelvis with the help of ureteroscope, and the distal end of the catheter was connected to saline for continuous drip, hanging at a height of about 40-60 cm from the surgical bed. The puncture site is selected between the 11th intercostal space or the 12th subcostal margin, between the posterior axillary line and the scapular line, and the middle calyx of the kidney is selected under the guidance of a special ultrasound puncture probe, and the 18G puncture needle is placed. Then introduce the guidewire, withdraw the puncture needle, use the plastic fascia dilator to dilate to F16, place the F8/9.8WOLF ureteroscope, confirm in the collecting system and then observe the renal calyces, renal pelvis, ureteric duct and upper ureteral stones, place the plastic thin sheath in the appropriate position, withdraw the ureteroscope, replace with the overlapping metal dilator to continue dilating to F22 along the guidewire, push in the F22 sheath and insert The F20.8WOLF nephroscope core is inserted along the ureteral catheter into the upper ureter, usually 6-8 cm from the connection. After the stone is found, the third-generation pneumatic ballistic combined with ultrasonic lithotripsy and adsorption system manufactured by EMS is used, including pneumatic ballistic lithotripsy system with high performance ultrasonic lithotripsy system and negative pressure suction system. For most of the ureteral stones, the ultrasonic lithotripsy and negative pressure suction system is used directly without the use of the pneumatic ballistic lithotripsy system, and the ultrasonic probe is placed along the nephroscope into the upper ureter and aimed at the stones to break the stones while suctioning them out of the body until they are cleared. For extremely hard stones, a combination of pneumatic ballistics, ultrasound and negative pressure adsorption systems can be used to crush and remove the stones. The renal pelvis and calyces are examined, and combined kidney stones are removed with this system. Finally, the F6 double J tube is placed in the same line, and the F14 nephrostomy tube is withdrawn and placed. The KUB was rechecked 3-5 days after surgery, and the nephrostomy tube could be removed if there was no stone left and the double J tube was in normal position. 2 Results All 22 patients were successfully punctured at one time, and the operation time was 55-95 min, with an average of 78 min; however, it only took 3-20 min, with an average of 11 min, from the discovery of stones by nephroscopy to the clean removal of stones; the average intraoperative bleeding was about 80 ml, and no blood was transfused; the average hospital stay was 6 days; no complications such as ureteral perforation, haemorrhage and serious infection occurred. The KUB was rechecked 3-5 days after the operation, and all of them had no stone residue and the stone removal rate reached 100%. 3 Discussion The common methods for the management of upper ureteral stones include extracorporeal shock wave lithotripsy (ESWL), transurethral ureteroscopic lithotripsy (URL), and ureterotomy for stone extraction (including open surgery and retroperitoneal laparoscopy). However, the efficacy of ESWL is very unsatisfactory for embedded stones. For transurethral ureteroscopic lithotripsy, it has been estimated that about 30% of stones or their fragments return to the kidney during the procedure and require adjunctive ESWL treatment. Ureterotomy for stone extraction is more invasive and is now rarely used. The traditional percutaneous nephrolithotomy (F 30-36) has been used to treat large stones in the upper ureter with good results, but its clinical application is limited by the large dilated channels, which can easily cause intraoperative and postoperative renal bleeding, postoperative urinary leakage, and perirenal hematoma complications. In recent years, minimally invasive percutaneous percutaneous nephrolithotomy (MPCNL) has been widely carried out. Since only F14-16 renal puncture channels are used, there is less damage to the kidney, less bleeding and significantly fewer complications, but it can only be operated with F8/9.8 ureteroscope, using pneumatic ballast or laser to break up the stone, and the stone cannot be directly aspirated, but cleared by means of clamping or perfusion flushing, and there are stones toward the the lower and middle ureter or the possibility of returning to the kidney, thus losing the opportunity to remove the stone in one stage [1]. Our approach is to puncture the middle calyces of the kidney under ultrasound guidance and dilate the channel to F22, and to aspirate the stones while breaking them through an F20.8WOLF nephroscope with the placement of ultrasound and/or pneumatic ballistic probes in combination with a third-generation ballistic ultrasound and negative pressure adsorption system manufactured by EMS, Switzerland, with satisfactory results. This method is much less damaging to the kidney than the traditional percutaneous nephrolithoscopy, and can avoid the massive bleeding caused by interlobular vascular injury due to renal parenchymal tear. It also has a larger field of view than MPCNL, and lithotripsy and lithotripsy are performed simultaneously, which greatly improves the efficiency of stone extraction without increasing the chance of bleeding. The third-generation pneumatic ballistic lithotripsy combined with ultrasound lithotripsy and adsorption device manufactured by EMS, Switzerland, combines pneumatic ballistic lithotripsy system with high performance ultrasound lithotripsy system and negative pressure adsorption system, each system can be used separately or simultaneously, which can not only break the stone rapidly, but also suck out the stone at the same time without changing instruments or equipment. In vitro studies have shown that the device is significantly more efficient in crushing and removing stones than single pneumatic ballistics or ultrasound lithotripsy [2, 3]. In clinical application, the device was found to significantly shorten the operation time and improve the stone removal rate per unit time, and it has good comminution effect on stones of different compositions, which significantly improves the clinical efficacy [4, 5]. Summarizing the experience of 22 cases, we believe that this method has the following advantages in the management of upper ureteral stones: ① The efficiency of stone removal is extremely high. The average time from stone discovery to stone removal was only 11 min in this group of cases. ② The stones will not be displaced when the stones are smashed and suctioned out at the same time, which avoids stones from descending to the middle and lower ureter or returning to the kidney, and improves the stone removal rate in the first stage, which was 100% in this group. ③ Sometimes stones or debris are wrapped by mucosa or polyps, which are difficult to remove, but can be easily solved by using ultrasound and negative pressure adsorption system. ④ The stone extraction procedure does not require stone extraction forceps and does not require the operating mirror to repeatedly enter and exit the stone extraction channel, which reduces a large number of tedious steps and significantly shortens the operation time. ⑤ Combined kidney stones can be treated simultaneously. In conclusion, percutaneous nephrolithoscopic pneumatic ballistic combined with ultrasonic lithotripsy for the treatment of large stones in the upper ureter is less invasive, has a high stone removal rate, quick recovery, safe and efficient, and is worth promoting.