Flexible ureteroscopy in extreme elderly patients (80 years of age and older) is feasible and safe

An international delphi survey and consensus meeting to define the risk factors for ureteral stricture after endoscopic treatment for urolithiasis

PURPOSE

Iatrogenic ureteral strictures (US) after endoscopic treatment for urolithiasis represent a significant healthcare concern. However, high-quality evidence on the risk factors associated with US is currently lacking. We aimed to develop a consensus statement addressing the definition, risk factors, and follow-up management of iatrogenic US after endoscopic treatment for urolithiasis.

METHODS

Utilizing a modified Delphi method, a steering committee developed survey statements based on a systematic literature review. Then, a two-round online survey was submitted to 25 experts, offering voting options to assess agreement levels. A consensus panel meeting was held for unresolved statements. The predetermined consensus threshold was set at 70%.

RESULTS

The steering committee formulated 73 statements. In the initial survey, consensus was reached on 56 (77%) statements. Following in-depth discussions and refinement of 17 (23%) statements in a consensus meeting, the second survey achieved consensus on 63 (86%) statements. This process underscored agreement on pivotal factors influencing US in endoscopic urolithiasis treatments.

CONCLUSIONS

This study provides a comprehensive list of categorized risk factors for US following endoscopic urolithiasis treatments. The objectives include enhancing uniformity in research, minimizing redundancy in outcome assessments, and effectively addressing risk factors associated with US. These findings are crucial for designing future clinical trials and guiding endoscopic surgeons in mitigating the risk of US.

Recurrent Urinary Stone Formers: Imaging Assessment and Endoscopic Treatment Strategies: A Systematic Search and Review

Background/Objectives: Nephrolithiasis is a heterogeneous disease with a high prevalence and recurrence rate. Although there has been much progress regarding the surgical treatment of stones, a standardized follow-up, especially in recurrent stone formers (SFs), has yet to be decided. This fact leads to the overuse of computed tomography (CT) scans and many reoperations in patients, thus increasing their morbidity and the financial burden on the health systems. This review systematically searched the literature for original articles regarding imaging strategies and endoscopic treatment for patients with recurrent urolithiasis, aiming to identify optimal strategies to deal with these patients. Methods: We systematically searched the Medline database (accessed on 1 April 2024) for articles regarding imaging modalities and endoscopic treatment for patients with recurrent urinary tract lithiasis. Results: No specific follow-up or endoscopic treatment strategy exists for patients with recurrent urolithiasis. CT scan was the imaging modality most used in the studies, followed by X-ray, ultrasonography, and digital tomosynthesis. A transparent algorithm could not be identified. Percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and ureteroscopy (URS) were used in the studies for endoscopic treatment. PCNL showed the best stone-free (SFr) rate and lowest hazard ratio (HR) for reoperation. RIRS showed superiority over extracorporeal shockwave lithotripsy for recurrent SFs, but fragments over 4 mm increased the recurrent rate. URS has an increased HR for reoperation for bilateral stones. Conclusions: The heterogeneity of urolithiasis leaves urologists without a standardized plan for recurrent SFs. Thus, each patient's follow-up should be planned individually and holistically. Pre-stenting is not to be avoided, especially in high-risk patients, and SFr status needs to be the aim. Finally, CT scans should not be generally overused but should be part of a patient's treatment plan. Prospective studies are required to define SFr status, the size of significant residual fragments, and the modalities of intervention and follow-up.

Ureteral stricture rate after endoscopic treatments for urolithiasis and related risk factors: systematic review and meta-analysis

PURPOSE

We aimed to accurately determine ureteral stricture (US) rates following urolithiasis treatments and their related risk factors.

METHODS

We conducted a systematic review and meta-analysis following the PRISMA guidelines using databases from inception to November 2023. Studies were deemed eligible for analysis if they included ≥ 18 years old patients with urinary lithiasis (Patients) who were subjected to endoscopic treatment (Intervention) with ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or shock wave lithotripsy (SWL) (Comparator) to assess the incidence of US (Outcome) in prospective and retrospective studies (Study design).

RESULTS

A total of 43 studies were included. The pooled US rate was 1.3% post-SWL and 2.1% post-PCNL. The pooled rate of US post-URS was 1.9% but raised to 2.7% considering the last five years' studies and 4.9% if the stone was impacted. Moreover, the pooled US rate differed if follow-ups were under or over six months. Patients with proximal ureteral stone, preoperative hydronephrosis, intraoperative ureteral perforation, and impacted stones showed higher US risk post-endoscopic intervention with odds ratio of 1.6 (P = 0.05), 2.6 (P = 0.009), 7.1 (P < 0.001), and 7.47 (P = 0.003), respectively.

CONCLUSIONS

The overall US rate ranges from 0.3 to 4.9%, with an increasing trend in the last few years. It is influenced by type of treatment, stone location and impaction, preoperative hydronephrosis and intraoperative perforation. Future standardized reporting and prospective and more extended follow-up studies might contribute to a better understanding of US risks related to calculi treatment.

Is ureteroscopy and active stone treatment safe and effective in octogenarians? A review of current literature

Background

With the aging of our patient population, and the increasing incidence of kidney stone disease in the elderly, active stone treatment is becoming more common. In this review of current literature, we aim to assess safety and efficacy of ureteroscopy (URS) as primary treatment for urolithiasis in the octogenarians.

Materials and methods

A scoping review of literature according to the PRISMA guidelines was performed, using the relevant search terms. Original articles were screened and included. A narrative review of the studies is provided, with emphasis on outcomes of URS in the elderly.

Results

10 studies were included in the analysis. URS performed in the elderly population showed a good safety and efficacy, with stone-free rates (SFR) comparable to the general population. URS specific complication rates seems to be comparable to the other age groups, with postoperative events mostly related to anaesthesia and pre-existing medical conditions. The overall complication rate was still low, with a slightly prolonged hospital stay. Predictors for SFR were age, severe comorbidities and stone burden.

Conclusion

URS for stone treatment in the elderly population is safe and effective, with comparable surgical outcomes to that of the general population. As comorbidities play an important role in the fitness for surgery and overall survival, risks and benefit of active stone treatment should be carefully balanced in this group.

Does age impact outcomes of retrograde intrarenal surgery in the elderly? Results from 366 patients from the FLEXible ureteroscopy outcomes registry (FLEXOR)

BACKGROUND

There has been a consistent increase in the last decades in prevalence of renal stones in elderly.

AIMS

To evaluate outcomes of retrograde intrarenal surgery (RIRS) for renal stones in elderly and factors associated with postoperative complications and residual fragments (RFs).

METHODS

Data from 12 centers were retrospectively reviewed.

INCLUSION CRITERIA

 ≥ 75 years, renal stones only, normal renal anatomy. Patients were divided into three groups; Group 1: patients aged 75-79 years; Group 2: age 80-84 years; Group 3: age ≥ 85 years. Multivariable logistic regression analyses were performed to assess factors associated with perioperative complications, sepsis, and RFs.

RESULTS

366 patients were included. There were 189 patients in Group 1, 113 in Group 2, and 64 in Group 3. There was no difference between groups regarding stone features and total surgical time. Median length of stay was significantly longer in Group 3 (6.0 days, vs 2.0 days in Group 2 vs 2.5 days in Group 1, p = 0.043). There was no significant difference in postoperative complications and RFs between the groups. At multivariable logistic regression analysis, female gender (OR 2.82) and maximum stone diameter (OR 1.14) were associated with higher odds of sepsis, while surgical time (OR 1.12) and the use of a reusable ureteroscope (OR 6.51) with overall complications. Stone size (OR 1.23) was associated with higher odds of RFs.

CONCLUSION

RIRS showed safety and efficacy for kidney stones in elderly patients. Surgical time should be kept as short as possible to avoid higher odds of postoperative complications, particularly in females.

Ureteroscopy in the elderly: safety and functional results

PURPOSE

To evaluate the effectiveness and safety of ureteroscopy (URS) for urinary stones treatment in patients ≥ 80 years of age.

METHODS

From 2012 to 2021, 96 patients ≥ 80 years underwent URS for urinary stone disease. Patients' demographics and surgical outcomes were examined.

RESULTS

The median length of follow-up was 25 months. Median age was 84 years. Half of the patients (53%) were ASA score 3 and 16% ASA 4. Mean stone diameter (SD) was 10.6 mm, and mean procedure time was 78 min. Eighty-three patients underwent follow-up imaging (ultrasonography or computed tomography) with a median time of 31 days. Stone-free rate was 73.9%. Twenty patients (20.7%) experienced a minor complication [Clavien-Dindo (CD) I-II] whereas five (5.7%) experienced a major complication (CD III-V). SD ≥ 10 mm predicted CD III-V complications (OR 1.25, 95% CI 1.01-1.55, p = 0.03). Urinary drainage prior the procedure with double J stent, nephroureteral stent or percutaneous nephrostomy tube had no impact on patients' SFR [74.6% in the drained group versus 64.0% in the undrained group (p = 0.44)] nor on major complications (OR 4.68, 95% CI 0.25-87.77, p = 0.30).

CONCLUSION

In elderly patients, URS for treatment of renal and ureteral stones is a relatively efficient and safe procedure. The risk of major complications is low, and the only associated risk factor found was SD ≥ 10 mm. Urinary drainage prior the procedure did not affect patients' outcomes.

Stone-event-free survival after ureteroscopic lithotripsy by age: comparison between young and older patients

The aim of this study is to examine stone-event-free survival after ureteroscopic lithotripsy (URSL) and risk factors for stone events by age. We retrospectively collected data of all URSL cases at our institution from 2008 to 2021. A total of 1334 cases were included and divided into young (< 65 years, 792 cases), young-old (65-74 years, 316 cases), old-old (75-84 years, 172 cases), and oldest-old (≥ 85 years, 54 cases) groups. Patient characteristics, surgical outcomes, and postoperative stone events were evaluated. The stone-event-free survival and risk factors were compared between young and older groups. Overall, 214 (16.0%) cases developed stone events during a mean follow-up period of 763 days and the 2-year, 5-year, and 8-year stone-event-free survival rates were 84.5%, 72.2%, and 57.2%, respectively. The numbers of stone events in young, young-old, old-old, oldest-old groups were 133 (16.8%), 53 (16.8%), 21 (12.2%), and 7 (13.0%), respectively. No significant differences were found in stone-event-free survival between the young group and each of the older groups. Residual fragment > 4 mm and stone burden ≥ 15 mm were common risk factors in both young and older groups. Especially in older patients, preoperative stenting, which was most often performed to treat obstructive pyelonephritis, was the third risk factor. In conclusion, stone-event-free survival after URSL was comparable between young and older patients. Residual fragment > 4 mm and stone burden ≥ 15 mm were common risk factors in both groups. Preoperative stenting was an additional risk factor in older patients, suggesting that urinary tract infection may influence stone events.

Ureteroscopy for Stone Disease in Extremely Elderly Patients (≥85 Years): Outcomes and Lessons Learned

Introduction: The volume of surgeries including ureteroscopy (URS) performed for urolithiasis is increasing. This includes for the elderly population. The aim of this study was to evaluate the outcomes of URS in extremely elderly patients and identify any lessons that could be learned for clinical practice and treatment planning. Materials and Methods: Retrospective analysis was performed of consecutive patients aged 85 years and older undergoing URS between 2010 and 2022 at our tertiary center. Uni- and multivariable logistic regression analyses were performed to identify possible risk factors for complications. Survival analysis, stratified by age-adjusted Charlson Comorbidity index (ACCI), was performed using the Kaplan-Meier method as well as the log-rank test. Results: Sixty-four URS procedures were performed on 51 patients (mean age 88 years, range 85-97). Mean ACCI score was 7 (range 4-13) and most patients were American Society Anesthesiologists 3 (78%). Mean operative time and hospital stay were 60 minutes (range 15-120) and 2 days (range 0-6), respectively. At 3-month follow-up imaging, 92% were stone free (zero fragments). Intraoperative complication rate was 14% and in three cases (5%), early termination of the procedure was necessary. Eight patients (13%) suffered a complication before discharge. Eighteen patients (28%) had documented late complications after their surgery. The complication rate when combining early and late adverse events was 41%. One year mortality rate was 23%. Multivariable regression analysis revealed that operation time and ACCI >7 were significant predictors of complications after surgery. Survival probability was significantly worse in those patients with ACCI >7 (p = 0.0083). Conclusion: The morbidity burden of URS in the extremely elderly is higher than for other population groups. Risk should be considered carefully and implementation of ACCI can aid this process. High scores should prompt strong consideration of a conservative approach. Operation time should be kept to a minimum wherever possible.

Comparison and Evaluation of Outcomes of Ureteroscopy and Stone Laser Fragmentation in Extremes of Age Groups (≤10 Years and ≥80 Years of Age): A Retrospective Comparative Analysis of over 15 Years from 2 Tertiary European Centres

AIM

To assess and compare the outcomes associated with ureteroscopy and laser fragmentation (URSL) for extremes of age group (≤10 and ≥80 years).

METHODS

Retrospective consecutive data were collected from two European centres for all paediatric patients ≤10 undergoing URSL over a 15-year period (group 1). It was compared to consecutive data for all patients ≥80 years (group 2). Data were collected for patient demographics, stone characteristics, operative details, and clinical outcomes.

RESULTS

A total of 168 patients had 201 URSL procedures during this time (74 and 94 patients in groups 1 and 2 respectively). The mean age and stone sizes were 6.1 years and 85 years, and 9.7 mm and 13 mm for groups 1 and 2 respectively. While the SFR was slightly higher in group 2 (92.5% versus 87.8%, p = 0.301), post-operative stent rate was also significantly higher in the geriatric population (75.9% versus 41.2%, p = 0.0001). There was also no significant difference in pre-operative stenting (p = 0.886), ureteric access sheath use (UAS) (p = 0.220) and post-operative complications. Group 1 had an intervention rate of 1.3/patient as compared to 1.1/patient in group 2. The overall complications were 7.2% and 15.3% in groups 1 and 2 respectively (0.069), with 1 Clavien IV complication related to post-operative sepsis and brief ICU admission in group 2.

CONCLUSION

The paediatric population had a marginally higher incidence of repeat procedure, but the overall SFR and complications were similar, and post-operative stent insertion rates were much better compared to geriatric patients. URSL is a safe procedure in the extremes of age groups with no difference in the overall outcomes between the two groups.

Active stone removal is a safe option for ocotogenarians and nonagenarians with nephrolithiasis

PURPOSE

To assess the contemporary in-hospital management of octogenarians and nonagenarians with renal calculi.

MATERIAL AND METHODS

A multicentric retrospective evaluation of patients aged ≥ 80 years hospitalized with kidney stones between 01/2000 and 12/2019. Stone and patient related data were collected, including stone size and location, geriatric status and comorbidities. Surgical treatment patterns and outcome were assessed.

RESULTS

A total of 299 patients (57% female) with kidney stones were analyzed. Mean age was 84.7 years. Patients were largely multimorbid (ASA ≥ 3 in 70%) and about 25% were classified as frail. Active stone treatment was performed in 65% and 35% were treated with urinary diversion (stent or nephrostomy). Prognostic factors for receiving an active stone treatment were age < 90 years, male sex, stone size and quantity, and performance status. Mean overall survival was 23.7 months and when stratified to treatment mean survival were 21 months after urinary diversion, 28 months after URS, 29 months after PCNL and 45 months after SWL.

CONCLUSION

Age, frailty and performance-status as well as stone size and quantity are predictors for active stone treatment. Octogenarians and nonagenarians, who are considered fit for surgery, tend to live long enough to profit from active stone treatment.

Safety and efficacy of ureteroscopy for urolithiasis in octogenarians

OBJECTIVE

To examine the safety and efficacy of ureteroscopy (URS) for urolithiasis in octogenarians, and identify preoperative risk factors for the incidence of postoperative complications.

METHODS

The patients who underwent URS for urolithiasis were divided into octogenarians and younger patients (age: <80 years), and the groups were compared regarding their clinical characteristics, intraoperative and postoperative complications, and stone-free rate. The predictors of postoperative complications were evaluated using logistic regression models.

RESULTS

A total of 1207 patients were included, 166 in the octogenarian patient group and 1041 in the younger patient group. The proportion of female patients (p < 0.001), American Society of Anesthesiologists (ASA) score (p < 0.001), rate of preoperative pyelonephritis (p < 0.001), and diabetes mellitus (p = 0.003) were higher in the octogenarian group. No statistically significant differences were found between the two groups regarding stone size, location, and intraoperative complications. Postoperative complications, which reached a significant difference, were observed in 34 (20.5%) octogenarians and 117 (11.2%) younger patients (p = 0.002). However, age itself was not significantly associated with postoperative fever, the most frequent postoperative complication, in multivariate analysis. Female sex, ASA score of ≥3, history of diabetes mellitus, and prolonged operative time (≥120 min) were the significant predictors of fever. The stone-free rate in the octogenarian group was superior to that in the younger patient group (80.1% vs. 70.6%, respectively; p = 0.035).

CONCLUSION

Our results suggest that URS for urolithiasis can be safely and effectively applied to octogenarians in selected cases.

Top Ten Tips Palliative Care Clinicians Should Know About Urological Care

Patients receiving palliative care (PC) can present with or develop a host of urological needs or complications. These needs can include attention to sexual health, urinary incontinence, genitourinary bleeding, and urinary tract obstruction by benign, malignant, or urinary stone diseases. These varied conditions require that PC clinicians understand invasive and noninvasive medical, surgical, and radiation options for treatment. This article, written by a team of urologists, geriatricians, and PC specialists, offers information and guidance to PC teams in an accessible "Top Ten Tips" format to increase comfort with and skills around assessment, evaluation, and specialist referral for urological conditions common in the PC setting.

Ureteral calculi in octogenarians and nonagenarians: Contemporary in-hospital management-A joint study by the endourological section of the Austrian Association of Urology

AIM

To assess contemporary in-hospital management of octogenarians and nonagenarians with ureteral calculi.

MATERIALS AND METHODS

Review of patients aged ≥80 years hospitalized due to ureteral calculi. Data was extracted from eight Austrian centers of urology. Stone and patient related data were recorded. Treatment patterns in acute and elective settings were assessed.

RESULTS

A total of 759 patients hospitalized with ureteral calculi were analyzed. Out of them, 643 were octogenarians (80-89years) and 116 nonagenarians (90-99 years). In an acute setting, simple de-obstruction with urinary diversions outnumbered active stone treatments like URS and SWL (62.6% vs. 26.9% vs. 10.5%). Decision making whether patients underwent active stone treatment was driven by stone location (OR = 0.28, p<0.0001), impaired renal function (OR = 0.28, p = 0.01) and indwelling urethral catheters (OR = 0.23, p = 0.01) but not by age or extend of mobility (all p>0.05). In elective settings, 81.5% of procedures were active stone treatments-mainly URS (76.9%), while DJ stent or nephrostomy replacements were noted in 14.2% and 4.3%. Octogenarians (OR = 14, p<0.0001) and patients capable of walking (OR = 4.51, p = 0.01) had significantly higher odds of receiving active stone. Stone free rates and complications rates with URS were similar between octogenarians and nonagenarians (p = 0.98 and p = 0.58).

CONCLUSION

In acute settings, age and extend of mobility were not found to be independent predictors for active stone treatment. In elective settings, after having received urinary diversions, reduced mobility and nonagenarians were less likely to undergo stone removal treatments. Safety and efficacy of URS seems to be similar in octogenarians and nonagenarians.

Comparison of flexible ureteroscopy and mini-percutaneous nephrolithotomy in the treatment for renal calculi larger than 2 cm: a matched-pair analysis

To compare the effectiveness and safety of flexible ureteroscopy and mini-percutaneous nephrolithotomy for renal calculi > 2 cm and perform subgroup analysis of stone length and age. Patients received mini-percutaneous nephrolithotomy or flexible ureteroscopy in Qilu Hospital of Shandong University from 2016.01 to 2021.03 with renal calculi > 2 cm were retrospectively analyzed. Propensity score matching was performed to get comparable patients. The postoperative hospital days, operation time, complication rate, and stone free rate were compared. The age and stone length were analyzed by subgroup. 162 in 313 patients were finally included. Each group had 81 cases. Outcomes such as intraoperative transfusion, stone free rate show no difference either. Flexible ureteroscopy had shorter postoperative hospital days (3.2 days vs 7.2 days, P < 0.001) and fewer complications (9, 11.1% vs 25, 30.9%, P = 0.002) compared to mini-percutaneous nephrolithotomy. The postoperative hospital days, and complication of the flexible ureteroscopy were significantly lower than those in the mini-percutaneous nephrolithotomy for renal stones ≤ 2.5 cm; when the stone length > 2.5 cm, the stone free rate of flexible ureteroscopy was lower than that of the mini-percutaneous nephrolithotomy group, but not statistically significant. The complications of flexible ureteroscopy in the young group (18-39 years old) were significantly lower than those in the mini-percutaneous nephrolithotomy group. For 2-2.5 cm renal stones, flexible ureteroscopy can achieve a similar stone free rate with shorter hospital stay, and lower complications. For larger stones, flexible ureteroscopy performed poorly. Flexible ureteroscopy may be a better option for younger patients with fewer complications.

Can We Identify Patients in Danger of Complications in Retrograde Intrarenal Surgery?-A Retrospective Risk Factors Analysis

Retrograde intrarenal surgery (RIRS) is an innovative and effective method of kidney stones treatment, as it had great influence on the development of endoscopy in urology. The increasing prevalence of urolithiasis together with the rapid development of endourology leads to a rise in the number of procedures related to the disease. Flexible ureteroscopy is constantly being improved, especially regarding the effectiveness and safety of the procedure. The purpose of this study is to evaluate intraoperative and early post-operative complications of RIRS in the treatment of kidney stones. A retrospective analysis of medical records was performed. A series was comprised of 207 consecutive operations performed from 2017 to 2020. Complications occurred in 19.3% (n = 40) of patients. Occurrence according to the Clavien-Dindo scale was: 11.1% for grade I, 5.8% for grade II and 2.4% for grade IV. Infectious complications included SIRS (5.3%, n = 11) and sepsis (2.4%, n = 5). Statistical analysis revealed a correlation between acute post-operative infections and positive midstream urine culture, history of chronic or recurrent urinary tract infections, and increased body mass index (BMI). Furthermore, a significant correlation was observed between pain requiring the use of opioids with BMI over 25. Consequently, history of urinary tract infections, positive pre-operative urine culture, and increased BMI are considered risk factors and require appropriate management.

The Predictive Factors For Readmission And Rehospitalization After Retrograde Intrarenal Surgery. The Results of RIRSearch study group

Purpose Retrograde intrarenal surgery (RIRS) is a safe and effective treatment option for upper urinary tract stones smaller than 2cm. Although several studies have documented perioperative and postoperative complications related to RIRS, there exists limited data regarding the readmission and rehospitalization of patients after RIRS. The aims of the study were to document the rates of readmission and rehospitalization after RIRS and to determine the predictive factors for readmission and rehospitalization. Materials and Methods In this study, we retrospectively analyzed patients who underwent RIRS for the treatment of renal stone disease and were unexpectedly readmitted to the hospital within 30 days after discharge. The hospital admission systems were used to determine readmissions and rehospitalizations. Readmission and rehospitalization rates, causes, and treatment procedures were evaluated. Univariate and multivariate analyses of clinicodemographic properties were performed to evaluate possible predictive factors for readmission and rehospitalization after RIRS. Results A total of 1,036 patients were included in the study. Of these patients, 103 (9.9%) were readmitted to the hospital. Among these readmissions, 35 patients (33.9%) were rehospitalized and 14 (13.6%) underwent surgical intervention. The most common reasons for readmission were renal colic and fever. The presence of preoperative pyuria (odds ratio [OR] 1.86), stone volume (OR 1.54), postoperative complications (OR 3.66), and stone-free status (OR 0.46) were predictive factors for readmission, whereas hospitalization time (OR 1.32), postoperative complications (OR 9.70), and stone-free status (OR 0.06) were predictive factors for rehospitalization after RIRS. Conclusion Nearly 10% of patients who underwent RIRS were readmitted to the hospital within the first month after discharge, and some were rehospitalized. Preoperative pyuria, high stone volume, presence of postoperative complications, and low stone-free status predicted this readmission and rehospitalization. Clinicians must recognize these predictive factors and inform their patients about this possibility.