Flexible ureteroscopic lithotripsy for the treatment of upper urinary tract calculi in infants

We evaluated the clinical value of flexible ureteroscopic lithotripsy for the treatment of upper urinary tract calculi in infants. Fifty-five infants with upper urinary tract calculi were included in this study: 41 males and 14 females. Retrograde intrarenal surgery was performed by an 8 Fr/30 cm flexible ureterorenoscope (POLY®) combined with a holmium laser. CT scanning or radiography of the kidneys, ureters, and bladder region was performed one month after the operation to confirm the clearance of calculi. All the 55 infants with calculi in 74 sides underwent 66 flexible ureteroscopic lithotripsy procedures. The median operation time was 30 min. The median amount of flushing fluid was 500 mL. The stone-free rate after a single session treatment was 94.6%, within which 10 infants underwent simultaneous bilateral flexible ureteroscopy lithotripsy. Catheters were retained in 45 infants for 24-48 h after the operation. Continuous high fever due to reflux was present in two cases. Flushing fluid extravasation was found in one infant. Some patients with minor complications, such as mild hematuria, irritation symptoms, and low fever, recovered without treatment. The duration of hospitalization time after the operation was approximately 1-5 days. Flexible ureteroscopic lithotripsy is a safe, highly efficient, minimally invasive, and reproducible operation for removal of upper urinary tract calculi in infants. This technique is a convenient method for postoperative management of patients that enhances their rapid recovery. It is a promising option for therapy of infants ineffectively treated by extracorporeal shockwave lithotripsy.

First clinical evaluation of a new single-use flexible ureteroscope (LithoVue™): a European prospective multicentric feasibility study

INTRODUCTION

We evaluated a new digital single-use flexible ureteroscope, LithoVue™ with respect to deflection, image quality and maneuverability.

METHODS

A prospective cohort study was conducted in eight tertiary reference centers in Europe in December 2015 and January 2016. All consecutive patients included underwent flexible ureteroscopy and were 18 years or older. Deflection and image quality pre- and post-use and maneuverability were rated with a Likert scale.

RESULTS

A total of 40 procedures were performed (five per institution). The indication for FURS was treatment of renal stones in 92.5 % of the cases. Before LithoVue™ usage, the median measured upward and downward deflections were both 270°. Image quality was rated as "very good" in 65 % of cases and "good" in 30 %. Maneuverability was "very good" in 77.5 % and "good" in 17.5 %. At the final evaluation, median upward and downward deflections were both 270°. Image quality was still "very good" in 65 % of cases and "good" in 30 % with no significant difference compared with preoperative data (p = 1). Maneuverability was "very good" in 72.5 % and "good" in 17.5 %, with no significant difference compared with preoperative data (p = 0.92). Two LithoVue™ broke during surgery (5 %): one occurring in extreme deflection with acute infundibulopelvic angle and spontaneous loss of vision for the second one.

CONCLUSION

The LithoVue™ displayed good image quality, active deflection and maneuverability. Further evaluation of surgical outcomes and cost analysis will help to present the best utility of this single-use FURS in current practice.

The surgical experience influences the safety of retrograde intrarenal surgery for kidney stones: a propensity score analysis

The aim of this study is to evaluate if surgical experience could influence the outcomes of retrograde intrarenal surgery (RIRS) in terms of stone clearance and complication rate. Patients from five institutions were included in this study. Patients were divided into two groups. Group 1: patients treated by three surgeons in the early phase of learning curve (surgical experience <100 procedures); Group 2: cases operated by two surgeons with great endourological experience (>400 procedures). Patients and stone characteristics, outcome and complications were analyzed. Multivariable regression model was used. Differences between groups were estimated using propensity scores to adjust for the bias inherent to the different characteristics. 381 RIRS were analyzed (Group 1: 150 RIRS; Group 2: 231 RIRS). Clinical data and stone parameters were comparable. The SFR was 70 % in Group 1 and 77.9 % in Group 2 (p = 0.082). Operative time was significantly shorter in the Group 2 (76.3 vs. 53.1 min, p = 0.001). The overall complication rate was significantly lower in Group 2 (20.7 vs. 8.7, p = 0.001). At unadjusted analysis, a non-significant difference was found between centers on SFR (OR 1.51 95 % CI 0.95-2.41). Conversely, a significant difference was found on overall complications (OR 0.36 95 %CI 0.20-0.67) with lower overall complication in Group 2. This study shows that surgeon experience influences the outcomes of RIRS mainly in terms of safety. Further studies will be needed to assess the exact number of procedures necessary to obtain a plateau in the rate of complications and success.

Flexible ureteroscopy versus laparoscopy for the treatment of patients who initially presented with obstructive pyelonephritis

Objective:

To compare the safety and effectiveness of flexible ureteroscopy (F-URS) with transperitoneal laparoscopic ureterolithotomy (TPLU) in cases of obstructive pyelonephritis secondary to large proximal ureteral stones.

Methods:

A series of 42 patients presenting with obstructive pyelonephritis due to proximal ureteral stones larger than 1.5 cm were included from April 2006 to February 2015 in this comparative study. After drainage of pyonephrosis and resolution of sepsis, 22 patients treated with TPLU (Group I), and 20 patients were treated with F-URS (Group II). Preoperative patient and stone characteristics, procedure-related parameters and clinical outcomes were assessed for each group.

Results:

It was seen that both methods were effective in the treatment of large proximal ureteral stones. However TPLU provided a higher stone- free rate (100% vs 80%. p=0.043) and lower retreatment rate. There was no difference between the groups for the operative time and complication rate. On the other hand, patients treated with F-URS had less postoperative pain (p=0.008), a shorter hospital stay (p<0.001) and a faster return to daily activities (p<0.001).

Conclusions:

The results of our study show that both F-URS and TPLU are safe and effective surgical procedures for treatment of large proximal ureteral stones after controlling obstructive pyelonephritis. However, TPLU has a higher stone-free rate with comparable operating time and complication rate as compared to F-URS. On the other hand F-URS has the advantages of less postoperative pain, shorter hospital stay and faster return to daily activities.

Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks

BACKGROUND

Thanks to advancements in the endoscopic armamentarium, flexible ureteroscopy (fURS) has become a viable and attractive option for the treatment of renal stones because of its high stone-free rates (SFRs) and low morbidity.

OBJECTIVE

To describe our surgical technique for fURS, step-by-step, for the treatment of renal stones and to assess its effectiveness and safety.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of 316 consecutive patients who underwent fURS for renal stones at our institution between March 2014 and September 2015 was performed.

SURGICAL PROCEDURE

Ureteroscopy and laser lithotripsy using a standardized technique with last-generation flexible ureteroscopes.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Clinical data were collected in a dedicated database. Intraoperative and postoperative outcomes were assessed. A descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

The mean overall stone size was 16.5 ± 7.9mm. Ureteral access sheath placement was possible in 287 patients (90.8%). At 1-mo follow-up, the overall primary SFR was 79.1%; the secondary and tertiary SFRs were 89.5% and 91.5%, respectively. The mean operative time was 72.6 ± 27.5min. The mean number of procedures was 1.27. Complications were reported in 92 patients (29.1%) overall, with Clavien grade 1 in 55 patients (17.4%), grade 2 in 30 patients (9.5%), grade 3 in 6 patients (1.9%), grade 4 in 1 patient (0.3%), and grade 5 in none. The main limitation of the study was the retrospective nature.

CONCLUSIONS

The fURS procedure is safe and effective for the treatment of renal stones. A staged procedure is necessary to achieve stone-free status with large calculi.

PATIENT SUMMARY

Flexible ureteroscopy is an effective treatment with low complication rates for the majority of renal stones. Both the modern highly technological armamentarium and surgical know-how should be available.

Unplanned flexible ureteroscopy during percutaneous nephrolithotomy in the prone position

BACKGROUND

Over time, the prone position has been shown to be effective and safe for performing percutaneous nephrolithotomy. One of its disadvantages, however, is the inability to simultaneously perform an ureteroscopy after positioning the patient, which is feasible in the supine position. Our objective is to demonstrate the feasibility of implementing flexible ureteroscopy with the patient in the prone position.

MATERIAL AND METHODS

We present a case of percutaneous nephrolithotomy of partial staghorn calculi in the prone position during which access to the middle calyx was not possible. It was therefore necessary to conduct flexible ureteroscopy. The 64-year-old female patient had consulted for lumbar pain of 6 months of evolution.

RESULTS

We performed percutaneous nephrolithotomy in the prone position. After extracting calculi from the inner calyx and renal pelvis, access to the fragments located in the middle calyx could not be achieved. Rather than performing a new puncture, we decided to enter in a retrograde manner with a flexible ureteroscope, succeeding in extracting the residual calculi, leaving the patient completely free of calculi.

CONCLUSION

In our case, the implementation of retrograde flexible ureteroscopy was feasible without changing the patient's original position.

Comparison of minimally invasive percutaneous nephrolithotomy and flexible ureteroscopy for the treatment of intermediate proximal ureteral and renal stones in the elderly

The aim of this study is to compare the outcomes of flexible ureteroscopy (fURS) and minimally invasive percutaneous nephrolithotomy (mPNL) for the treatment of renal and/or proximal ureteral stones sized 1-2 cm in the elderly (≥60 years). Between January 2010 and March 2015, 184 consecutive mPNL and fURS were performed to treat intermediate renal and/or proximal ureteral stones in geriatric patients. The records were retrospectively reviewed and outcomes were compared. Although no significant difference was found in the complication rate between two groups, a statistical trend (p = 0.059) in favor of fURS was observed. In addition, multivariate analysis demonstrated that mPNL, preoperative positive urine culture and lower hemoglobin were independent risk factors for postoperative complication (p = 0.016, p = 0.021, p = 0.001, respectively). And fURS was significantly associated with less hemoglobin drop, red blood cell transfusion, analgesics requirement, postoperative hospital duration, and charges of laboratory tests, medical examinations and medications (p = 0.019, p = 0.037, p = 0.006, p = 0.000 and p = 0.007, p = 0.000, p = 0.000, p = 0.001, respectively), while higher costs of operations (p = 0.008). Receiver operating characteristic curve suggested a preoperative hemoglobin of 106.5 g/L as the threshold for predicting red blood cell transfusion after mPNL. The overall one-session stone-free rate of fURS at 1 month was lower (p = 0.006), while it was similar for solitary stone between two groups. Comorbidity and previous stone surgery did not affect postoperative complication and stone-free rate. This study shows that mPNL is more effective for multiple stones, but fURS is associated with potentially less complications and postoperative hospital stay. Furthermore, preoperative hemoglobin level and urine culture can be used to predict postoperative complication risk and they may be helpful in choosing treatment methods for the elderly.

Which factors affect the hospital re-admission and re-hospitalization after flexible ureterorenoscopy for kidney stone?

PURPOSE

To investigate patient- and procedure-related factors associated with hospital re-admission (HR) and re-hospitalization following flexible ureteroscopy (f-URS).

PATIENTS AND METHODS

The records of patients who underwent f-URS for renal stones in two reference centers between 2011 and 2015 were examined retrospectively. Patients who were re-admitted to the hospital or re-hospitalized for any reason within 30 days after hospital discharge related to the f-URS procedure were evaluated. The patient- and procedure-related factors affecting the re-admission and re-hospitalization rates were revealed using backward stepwise multiple binary logistic regression analysis.

RESULTS

The study included 647 patients with a mean age of 46.1 ± 13.7 years. The mean BMI was 27.3 ± 4.6 kg/m(2), and the median ASA score was 1.85. The mean stone diameter was 14.2 ± 5.3 mm. The mean operation and fluoroscopy times were 50.2 ± 16.9 min and 43.1 ± 37.6 s, respectively. The mean hospitalization time was 1.42 ± 0.84 days, and the complication rate was 12.8 % (83/647). Overall, 523 (80.3 %) patients became stone-free, while residual fragments <4 mm were detected in 73 (11.3 %) patients. The procedure failed in 7.9 % of the cases. While 82 (12.7 %) patients were re-admitted, 31 (4.8 %) patients were re-hospitalized for further treatment. Stone-free status was an independent predictor of HR, while the stone-free status, hospitalization time, and postoperative complications all predicted re-hospitalization.

CONCLUSIONS

We found that inability to achieve stone-free status predicted HR and re-hospitalization, while postoperative complication and prolonged hospitalization also predicted re-hospitalization.

[Impact of the acquisition of a flexible ureteroscope on the management of upper urinary tract stones in children]

INTRODUCTION

Firstly reported in the early 1990s for the treatment of upper urinary tract stones in adult patients, flexible ureteroscopy (F-URS) has been used in children during the past 10 years and is now considered as a viable, but still second-line alternative to extracorporeal shockwave lithotripsy in these patients (ESWL). The aim of this study was to assess the impact of the acquisition of a F-URS on the management of upper urinary tract stones in children.

PATIENTS AND METHODS

Data of all ESWL, F-URS and percutaneous nephrolithotomy performed for upper urinary tract stones in children from 0 to 18 years old in a single center from 2000 to 2014 have been collected retrospectively. Patients have been divided into two groups: group 1 before the acquisition of the F-URS (2000-2008) and group 2 after the acquisition of the F-URS (2008-2014). Preoperative data and peri-operative outcomes were compared between both groups using the χ(2) test and Fisher exact test for discrete variables and the Mann-Whitney test for continuous variables.

RESULTS

Thirty-seven children have been treated during the first era and 32 during the second one. The two groups were similar in terms of age (7.2 years vs 8.1 years; P=0.54), size of the largest stone (15 mm vs 16.2mm; P=0,56) and number of stones per patient (1.4 vs 2; P=0,07) but the sum of stone diameters was higher in group 2 (16.9 mm vs 24.2mm; P=0,048). The stone-free rates were comparable in both groups (28.1% vs 32.2% after the first procedure; P=0.72), as were the mean number of procedures per patient (2.4 vs 2.5; P=0.78), the total length of stay (2.7 days vs 2.9 days; P=0.77), and the number of patients who experienced at least one complication (37.8% vs 40.6%; P=0.87).

CONCLUSION

The acquisition of a F-URS allowed the treatment of more complex stones with a similar efficacy and without increasing morbidity. Further studies are needed to define the role of F-URS in the management of upper urinary tract stones in children.

[Prognostic factors for severe infection after flexible ureteroscopy: Clinical interest of urine culture the day before surgery?]

OBJECTIVES

The objectives of this study have been to determine prognostic factors for acute pyelonephritis (AP) after flexible ureteroscopy (FU), to assess the frequency of readmission for AP and to study the usefulness of urinalysis the day before surgery.

METHODS

Between 2010 and 2013, 266 patients have had at least one ureteroscopy (n=325). All infectious complications and unplanned readmissions within the month after FU were retrospectively evaluated. Several data have been collected: age, sex, BMI, surgical indication (calculis or tumor), number of previous ureteroscopies, number of previous surgeries for calculis, stones number, size and location, bilateral interventions, operating time, preoperative ureteral stenting, postoperative stenting, hospitalization stay, urine culture the day before surgery (j-1) and prescription of antibiotic therapy the week before FU. Correlation between these variables and acute pyelonephritis (AP) the month following the USSR was tested (StatView 4.5, SAS Institute) (P<0.05 significant).

RESULTS

We observed 24 postoperative APs (7.4%), 17 prior to hospital discharge and 7 requiring rehospitalization. In univariate analysis, the significant prognostic factors of postoperative AP have been: stone size (>14 mm) (P=0.03); operating time (70 minutes) (P<0.005); positive day - 1 urine culture (P<0.001); antibiotics treatment the week before FU (P<0.001). In multivariate analysis, antibiotics prescription during the week before USSR remained significant (P<0.002; RR 5.8 [1.9-15]).

CONCLUSION

Acute pyelonephritis requiring unplanned admission after ureteroscopy is a rare complication (2.4%). Urinalysis one day before ureteroscopy could allow early antibiotic therapy and may reduce 63% of unplanned hospital admissions for acute pyelonephritis.

LEVEL OF EVIDENCE

5.

Influence of the renal lower pole anatomy and mid-renal-zone classification in successful approach to the calices during flexible ureteroscopy

PURPOSE

The aim of this paper is to analyze if the anatomy type of the collector system (CS) limits the accessibility of flexible ureteroscopy (FUR) in the lower pole.

METHODS

We analyzed the pyelographies of 51 patients submitted to FUR and divided the CS into four groups: A1-kidney midzone (KM) drained by minor calices (Mc) that are dependent on the superior or on the inferior caliceal groups; A2-KM drained by crossed calices; B1-KM drained by a major caliceal group independent both of the superior and inferior groups, and B2-KM drained by Mc entering directly into the renal pelvis. We studied the number of calices, the angle between the lower infundibulum and renal pelvis, and the angle between the lower infundibulum and the inferior Mc. With the use of a flexible ureteroscope, the access attempt was made to all of lower pole calices. Averages were statistically compared using the ANOVA and Unpaired T test (p < 0.05).

RESULTS

We found 14 kidneys of A1 (27.45 %); 4 of A2 (7.84 %); 17 of B1 (33.33 %); and 16 of B2 (31.37 %). The LIP was >90° in 31 kidneys (60.78 %) and between 61° and 90° in 20 kidneys (39.22 %). We did not find angles smaller than 60°. The group A1 presented 48 Mc and the UF was able to access 42 (87.5 %); the group A2 had 11 Mc and the UF was able to access 7 (63.64 %); the group B1 had 48 Mc and the UF was able to access 41 (85.42 %) and in group B2 we observed 41 Mc and the UF could access 35 (85.36 %). There was no statistical difference in the accessibility between the groups (p = 0.2610).

CONCLUSIONS

Collecting system with kidney midzone drained by crossed calices presented the lower accessibility rate during FUR.

The new concept of ureteral access sheath with guidewire disengagement: One wire does it all

PURPOSE

To prospectively evaluate the new Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) access sheath (UAS) which allows the use of a single wire to serve as both safety and working guide.

MATERIALS AND METHODS

Between June and September 2014, adult patients from five European centers who underwent flexible ureteroscopy (fURS) for therapeutic and diagnostic purposes were included. The 12/14Fr Flexor©Parallel™ UAS was evaluated. Data were collected and examined by both univariate and multivariate analyses. The UAS material and usage characteristics were rated per case by the surgeons on a scale from very bad to very good.

RESULTS

In total, 134 UASs were used in 67 male and 67 female patients. Fifty percent of ureters (67 patients) were pre-stented. Ninety percent of the procedures were therapeutic. The overall successful insertion rate was 94 %. Pre-stenting status was the only independent factor for a successful access sheath insertion: 98.5 % of the pre-stented patients had a successful UAS placement vs. 82 % of non-pre-stented (p = 0.001, C.I. 95 %: 1.2). Evaluation of the material and radiopacity was considered very good in over 90 % of cases. Release of the guidewire, hydrophilic coating, gliding of the endoscope and repeatability were considered very good in over 80 %. There were two (1.4 %) UAS malfunctions and one submucosal lesion reported.

CONCLUSIONS

The use of the Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) with usage of a single guidewire in a prospective multicentric scenario was clinically applicable in the majority of cases. Pre-stenting increased the chance of a successful insertion from 82 to 98.5 %.

Flexible ureteroscopy: Technological advancements, current indications and outcomes in the treatment of urolithiasis

The last 3 decades have witnessed great improvements in the technology and clinical applications of many minimally invasive procedures in the urological field. Flexible ureteroscopy (fURS) has advanced considerably to become a widely utilized diagnostic and therapeutic tool for multiple upper urinary tract pathologies. The most common indication for fURS is the treatment of upper urinary tract stones with the aid of Holmium:Yttrium Aluminium Garnet (YAG) laser lithotripsy. Advancements in endoscope technologies and operative techniques have lead to a broader application of fURS in the management of urolithiasis to include larger and more complex stones. fURS has proved to be an effective and safe procedure with few contraindications. Continued progression in fURS may increase its clinical applicability and supplant other procedures as the first line treatment option for urolithiasis.

Lower pole anatomy and mid-renal-zone classification applied to flexible ureteroscopy: experimental study using human three-dimensional endocasts

PURPUSE

The aim of this study was to analyze the anatomy of the inferior pole collecting system and the mid-renal-zone classification in human endocasts applied to flexible ureteroscopy.

METHODS

170 three-dimensional polyester resin endocasts of the kidney collecting system were obtained from 85 adult cadavers. We divided the endocasts into four groups: A1--kidney midzone (KM), drained by minor calices (mc) that are dependent on the superior or the inferior caliceal groups; A2--KM drained by crossed calices; B1--KM drained by a major caliceal group independent of both the superior and inferior groups; and B2--KM drained by mc entering directly into the renal pelvis. We studied the number of calices, the angle between the lower infundibulum and renal pelvis and the angle between the lower infundibulum and the inferior mc (LIICA). Means were statistically compared using ANOVA and the unpaired T test (p < 0.05).

RESULTS

We found 57 (33.53 %) endocasts of group A1; 23 (13.53 %) of group A2; 59 (34.71 %) of group B1; and 31 (18.23 %) of group B2. The inferior pole was drained by four or more calices in 84 cases (49.41 %), distributed into groups as follows: A1 = 35 cases (41.67 %); A2 = 18 (21.43 %); B1 = 22 (26.19 %); and B2 = 9 (10.71 %). Perpendicular mc were observed in 15 cases (8.82 %). We did not observe statistical differences between the LIICA in the groups studied.

CONCLUSIONS

Collector systems with kidney midzone drained by minor calices that are dependent on the superior or on the inferior caliceal groups presented at least two restrictive anatomical features. The mid-renal-zone classification was predictive of anatomical risk factors for lower pole ureteroscopy difficulties.

Retrograde intrarenal surgery with holmium-YAG laser lithotripsy in the primary treatment of renal lithiasis

INTRODUCTION

retrograde intrarenal surgery (RIRS) appears as a safe and effective technique as well as a good therapeutic alternative to extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL).

MATERIAL AND METHODS

descriptive study in 50 patients surgically treated between November 2012 and April 2013. Demographic, operative and postoperative data as well as early and late complications data were collected. The minimum follow-up of patients was one year. Surgery was performed under general anesthesia. Flexible ureteroscopy with ureteral access sheath and laser fragmentation were employed. Surgery success was defined as stone free rate in postoperative control test and at three months after surgery (simple radiography, abdominal ultrasound or CT without contrast).

RESULTS

mean age was 51.1±15.5 years old. The highest-frequency location was the lower calyceal group (26%), single stones were described in 58% of patients whilst multiple lithiasis were found in the 42%. Regarding the stone burden in 44% of the patients was low (<2 cm), and high (>3 cm) in 22% of the patients. The stone clearance rate was 89.7±17.5. Average surgery time was 96.6±35.2min. Complications were reported in 4 patients (8%), all of them early ones and minor in nature.

CONCLUSIONS

RIRS is an effective and safe option whose results are comparable to ESWL and PCNL. RIRS can be considered as first-line treatment. These results are corroborated by numerous studies. To strengthen these findings, prospective studies focusing on quality of life, length of stay, complications and cost-effectiveness of different treatments are needed.

A comparative study to analyze the efficacy and safety of flexible ureteroscopy combined with holmium laser lithotripsy for residual calculi after percutaneous nephrolithotripsy

A certain proportion of patients with initial Percutaneous nephrolithotripsy (PCNL) management require ancillary procedures to increase the stone-free rate. In this study, we aim to analyze the efficacy and safety of flexible ureteroscopy combined with holmium laser lithotripsy (F-UL) for treatment of residual calculi after PCNL by comparison with extracorporeal shockwave lithotripsy (SWL). Total of 96 patients with residual renal calculi (4 mm to 20 mm) after PCNL was enrolled from May 2010 to March 2013. They were randomly divided into two groups: US Group: patients were treated with F-UL; SWL Group: patients were treated with SWL. Follow-up was made one month and three months after treatment. The mean residual stone size after PCNL was 12.4 ± 4.3 mm in US group compared with 11.9 ± 4.5 in SWL group. The stone-free rate was 84.7% one month after surgical procedure in US group, this rate increased to 91.3% in the third months, while the stone-free rate in SWL group is 64.6% one month after treatment and 72.9% in the third month. For residual stone in lower calyx, the stone-free rate three month after treatment was 90.4% in US group compared to 65.2% in SWL group (P < 0.05). The overall complication rate was low in both groups, no severe complication was found. Both F-UL and SWL are safe and effective methods for residual calculi after PCNL, without severe complications. F-UL provided significantly higher stone-free rate compared with SWL, especially for low-pole calculi.

[Initial experience of first 225 flexible ureteroscopy with laser lithotripsy in a primary care hospital]

INTRODUCTION

During the last decade, the advent of flexible ureteroscopy with laser lithotripsy has revolutionized the management of upper urinary tract stones. Our center is a primary care hospital that is equipped with this technology since January 2011. This study reported our initial experience of first 225 cases.

MATERIEL AND METHODS

This study is a descriptive, retrospective and monocentric analysis. The first 225 cases, operated consecutively by 3 surgeons during 26 months, were analyzed. We have used 2 flexible ureteroscopes (1 digital, 1 optical). Laser source was an Holmium laser (Stonelight) at a power of 5 watts.

RESULTS

The mean age was 53 years (± 10.2) and the mean stones size was 11 mm (2.3). In 49% of cases, ureteroscopy was chosen for the first, without prior treatment. In 59% of cases, ureteroscopy was used after failure of other treatment (ESWL in 70% of cases). The mean operative time was 72 minutes (± 16.6) and the mean length of stay was 2.6 days (± 0.8). The first session of ureteroscopy was a success in 93% of cases without residual fragments after 1 month. The frequency of postoperative complications was estimated at 8% (Clavien I and II).

CONCLUSION

Flexible ureteroscopy with laser lithotripsy was a safe and effective technique, allowing the treatment of all upper urinary tract stones, especially on failure of other treatment. Its place in the first intention is widespread in our exercise, especially among obese patients, patients on anticoagulant therapy or with stone of the lower pole.

[Effectiveness of flexible ureteroscopy versus extracorporeal shock wave lithotripsy for kidney stones treatment]

Primary endpoint was to objective a better effectiveness of flexible ureteroscopy (fURS) compared to extracorporeal shock wave lithotripsy (ESWL) 3 months after treatment of a unique kidney stone from 5 to 20mm. Secondary endpoints were to evaluate effectiveness in subgroup and tolerance. We conducted a prospective comparative randomised trial between May 2012 and February 2014. A computerised tomography was done before treatment and another 3 months after treatment. Of the 30 randomised patients, 8 dropped out from the study and 4 were lost to follow-up. Median time of follow-up was 3.82 months. In per-protocol analysis, success rate was 60% for fURS group versus 28.6% for ESWL group (P=0.29). In intention to treat analysis, success rate was 77.8% in fURS group versus 53.8% in ESWL group (P=0.38). In ESWL group, 5 patients (41.7%) needed a second treatment versus none in fURS group but it was not significant. During follow-up, 1 patient in each group presented a complication. Results of this feasibility study did not allowed to conclude on superiority of a technic. A multicenter study with more important enrollment is necessary considering economic side and tolerance of these treatments.

Flexible ureteroscopy and lasertripsy (FURSL) for paediatric renal calculi: results from a systematic review

OBJECTIVE

To understand the role, safety and efficacy of flexible ureterorenoscopy and lasertripsy (FURSL) for paediatric renal stones.

MATERIAL AND METHODS

A systematic review was conducted using studies identified by a literature search between January 1990 and March 2014. All English language articles reporting on a minimum of five patients≤18-years old, treated with flexible ureteroscopy and lasertripsy for stone disease were included.

RESULTS

A total of six studies (282 patients) were reported, with a mean age of 7.3 years (range 0.25-17 years). The stone sizes ranged from 1 to 30 mm. The mean stone-free rate across the three studies was 85.5% (range 58.0-93.0%) after initial ureteroscopy, with a postoperative stent inserted in 81.8% (range 66.7-98.0%). There were a total of 35 complications (12.4%), with the most severe complication being a Clavien class III (five ureteral injuries, one urinoma). There were no deaths in any of the studies.

CONCLUSION

The present review shows that FURSL for management of renal calculi in the paediatric population is an effective and safe procedure. To ensure that outcomes keep on improving, these procedures should be undertaken by experienced surgeons who are familiar with the difficulties encountered in the paediatric population.

Flexible ureteroscopy for renal stones

OBJECTIVES

The objectives of this prospective study are to present our experience with retrograde intrarenal surgery (RIRS), and to analyze its results and complications.

MATERIAL AND METHODS

150 patients with renal stones were treated with RIRS. 111 cases showed single stones whilst multiple stones were observed in 39 cases. The mean size was 19.12mm (r: 5-74). Success rate was defined as the absence of residual stones or the presence of fragments ≤2mm.

RESULTS

in 21 (14%) patients RIRS could not be performed on first attempt because it was impossible to place the ureteral access sheath. The immediate success rate was 85.7%, and 91.6% at three months later. The average operating time was 85min (r: 25-220). Postoperative complications were observed in 22 cases (14.6%), although most of them were classified as Clavien 1 and 2 (19 cases), and only 2% (3 cases) showed Clavien 4 complications (sepsis requiring admission in the intensive care unit). 10 patients underwent a second procedure in order to complete the treatment. Thus, the number of procedures per patient was 1.06. There were no late complications.

CONCLUSIONS

the treatment of renal stones with flexible ureteroscopy using the ureteral access sheath shows a high successful rate with a low complication rate. In order to define its indication more precisely, randomized studies comparing RIRS with minimally invasive percutaneous nephrolithotomy procedures (miniperc and microperc) would be necessary.

Percutaneous nephrolithotomy versus retrograde intrarenal surgery: a systematic review and meta-analysis

CONTEXT

Recent advances in technology have led to the implementation of mini- and micro-percutaneous nephrolithotomy (PCNL) as well as retrograde intrarenal surgery (RIRS) in the management of kidney stones.

OBJECTIVE

To provide a systematic review and meta-analysis of studies comparing RIRS with PCNL techniques for the treatment of kidney stones.

EVIDENCE ACQUISITION

A systematic literature review was performed in March 2014 using the PubMed, Scopus, and Web of Science databases to identify relevant studies. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. A subgroup analysis was performed comparing standard PCNL and minimally invasive percutaneous procedures (MIPPs) including mini-PCNL and micro-PCNL with RIRS, separately.

EVIDENCE SYNTHESIS

Two randomised and eight nonrandomised studies were analysed. PCNL techniques provided a significantly higher stone-free rate (weighted mean difference [WMD]: 2.19; 95% confidence interval [CI], 1.53-3.13; p<0.00001) but also higher complication rates (odds ratio [OR]: 1.61; 95% CI, 1.11-2.35; p<0.01) and a larger postoperative decrease in haemoglobin levels (WMD: 0.87; 95% CI, 0.51-1.22; p<0.00001). In contrast, RIRS led to a shorter hospital stay (WMD: 1.28; 95% CI, 0.79-1.77; p<0.0001). At subgroup analysis, RIRS provided a significantly higher stone-free rate than MIPPs (WMD: 1.70; 95% CI, 1.07-2.70; p=0.03) but less than standard PCNL (OR: 4.32; 95% CI, 1.99-9.37; p=0.0002). Hospital stay was shorter for RIRS compared with both MIPPs (WMD: 1.11; 95% CI, 0.39-1.83; p=0.003) and standard PCNL (WMD: 1.84 d; 95% CI, 0.64-3.04; p=0.003).

CONCLUSIONS

PCNL is associated with higher stone-free rates at the expense of higher complication rates, blood loss, and admission times. Standard PCNL offers stone-free rates superior to those of RIRS, whereas RIRS provides higher stone free rates than MIPPs. Given the added morbidity and lower efficacy of MIPPs, RIRS should be considered standard therapy for stones <2 cm until appropriate randomised studies are performed. When flexible instruments are not available, standard PCNL should be considered due to the lower efficacy of MIPPs.

PATIENT SUMMARY

We searched the literature for studies comparing new minimally invasive techniques for the treatment of kidney stones. The analysis of 10 available studies shows that treatment can be tailored to the patient by balancing the advantages and disadvantages of each technique.

Retrograde intrarenal surgery for lower pole renal calculi smaller than one centimeter

Objectives:

Recently there has been an increasing interest in the application of retrograde intrarenal surgery (RIRS) for managing renal calculi. In this review we discuss its application for the management of lower calyceal (LC) stones less than 10 mm in maximum dimension.

Materials and Methods:

Literature was reviewed to summarize the technical development in flexible ureterorenoscopy and its accessories. Further, the indications, outcome and limitations of RIRS for LC calculi < 1 cm were reviewed.

Results:

Use of access sheath and displacement of LC stone to a more favorable location is increasingly employed during RIRS. Patients who are anticoagulated or obese; those with adverse stone composition and those with concomitant ureteral calculi are ideally suited for RIRS. It is used as a salvage therapy for shock wave lithotripsy (SWL) refractory calculi but with a lower success rate (46-62%). It is also increasingly being used as a primary modality for treating LC calculi, with a stone-free rate ranging from 50-90.9%. However, the criteria for defining stone-free status are not uniform in the literature. The impact of intrarenal anatomy on stone-free rates after RIRS is unclear; however, unfavorable lower calyceal anatomy may hamper the efficacy of the procedure. The durability of flexible ureteroscopes remains an important issue.

Conclusions:

RIRS continues to undergo significant advancements and is emerging as a first-line procedure for challenging stone cases. The treatment of choice for LC calculi < 1 cm depends on patient's preference and the individual surgeon's preference and level of expertise.