RIRS in the elderly: Is it feasible and safe?

Prevention, diagnosis, and treatment of urolithiasis in geriatric patients - differences, similarities and caveats in comparison to the general population

PURPOSE OF REVIEW

Purpose of the review is to address management and prevention of urolithiasis in elderly patients examining the dynamic interplay between general measures, dietary adjustments, lifestyle modifications, and targeted pharmacological and/ or surgical interventions. The goal is to provide understanding of the evolving strategies required for effective urolithiasis prevention in the geriatric population.

RECENT FINDINGS

Age-specific diagnostic considerations are necessary because urolithiasis in the elderly population is characterized by bigger stones, greater peri-operative risks, and heightened symptom severity. When comorbidities are present, conservative treatments - especially analgesia - provide difficulties. Surgical procedures prove to be safe and effective, with complication rates and practical application comparable to younger cohorts. Prevention approaches that include lifestyle changes and the investigation of novel pharmaceutical options such as sodium-dependent glucose co-transporter 2 (SGLT-2)-inhibitors are promising in the management of urolithiasis in the elderly population.

SUMMARY

Our review offers a thorough investigation of urolithiasis in the elderly population, elucidating distinct clinical manifestations, complex diagnostic issues, and treatment implications. The safety and effectiveness of ureteroscopy in older patients, as well as the possible prophylactic function of SGLT-2-I, offer crucial insights for clinicians. Subsequent studies are necessary to enhance age-specific therapies, addressing the distinct obstacles presented by urolithiasis in the elderly population within this rapidly growing demographic.

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.

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.

Management of large kidney stones in the geriatric population

PURPOSE

The aim of this review is to highlight the unique factors that predispose geriatric patients to nephrolithiasis and to compare the utility and efficacy of surgical techniques in this specific patient population.

METHODS

PubMed and EMBASE databases were reviewed, and studies were organized according to surgical treatments.

RESULTS

Few prospective studies exist comparing kidney stone removal in the elderly to younger cohorts. In addition, various age cut-offs were used to determine who was considered elderly. Most studies which analyzed Percutaneous Nephrolithotomy (PCNL) found a slightly higher rate of minor complications but comparable stone free rate and operative time. For ureteroscopy (URS) and extracorporeal shockwave lithotripsy (ESWL), there were minimal complications observed and no difference in clinical success in the elderly. All surgical techniques were presumed to be safe in the elderly and most found no difference in stone-free rates.

CONCLUSIONS

Unique attributes of the geriatric population contribute to stone formation and must be considered when determining appropriate management modalities. This review provides an overview of the utility and efficacy of PCNL, URS and ESWL in the elderly, as well as a porposed algorithm for management in this population.

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.

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.

A warning system for urolithiasis via retrograde intrarenal surgery using machine learning: an experimental study

Background

To develop a warning system that can prevent or minimize laser exposure resulting in kidney and ureter damage during retrograde intrarenal surgery (RIRS) for urolithiasis. Our study builds on the hypothesis that shock waves of different degrees are delivered to the hand of the surgeon depending on whether the laser hits the stone or tissue.

Methods

A surgical environment was simulated for RIRS by filling the body of a raw whole chicken with water and stones from the human body. We developed an acceleration measurement system that recorded the power signal data for a number of hours, yielding distinguishable characteristics among three different states (idle state, stones, and tissue–laser interface) by conducting fast Fourier transform (FFT) analysis. A discrete wavelet transform (DWT) was used for feature extraction, and a random forest classification algorithm was applied to classify the current state of the laser-tissue interface.

Results

The result of the FFT showed that the magnitude spectrum is different within the frequency range of < 2500 Hz, indicating that the different states are distinguishable. Each recorded signal was cut in only 0.5-s increments and transformed using the DWT. The transformed data were entered into a random forest classifier to train the model. The test result was only measured with the dataset that was isolated from the training dataset. The maximum average test accuracy was > 95%. The procedure was repeated with random signal dummy data, resulting in an average accuracy of 33.33% and proving that the proposed method caused no bias.

Conclusions

Our monitoring system receives the shockwave signals generated from the RIRS urolithiasis treatment procedure and generates the laser irradiance status by rapidly recognizing (in 0.5 s) the current laser exposure state with high accuracy (95%). We postulate that this can significantly minimize surgeon error during RIRS.

Effectiveness and Safety of Ureteroscopic Lithotripsy in Young, Old-Old, and Oldest Old Patients

Objectives: To investigate the efficacy and safety of ureteroscopic lithotripsy (URSL) in young, old-old, and oldest old patients. Materials and Methods: We enrolled 157 patients who underwent URSL. We divided the patients into young (<65 years), old-old (65-84 years), and oldest old (≥85 years) groups and compared the safety of surgery between young vs old-old and young vs oldest old, separately. Results: In the <65 group, 65 to 85 group, and ≥85 group, respectively, the mean stone diameters were 8.9 ± 4.9, 10.8 ± 7.7, and 11.4 ± 6.3 mm; mean operative time was 76.6 ± 33.1, 86.7 ± 44.7, and 84.0 ± 44.5 min; the stone-free rates were 95.9%, 94.4%, and 96.3%; and the complication rates were 8.2%, 9.8%, and 3.7%. Conclusions: In this study, we showed the feasibility and safety of URSL for elderly people. Although oldest old (≥85 years) people had multiple comorbidities with low performance status, URSL could be performed with acceptable complication rates. Clinical Trial Registration Number: 1809-1.

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

PURPOSE

To compare the safety and efficacy of RIRS in patients ≥ 80 years to a younger population.

METHODS

We retrospectively compared the data from patients ≥ 80 years of age undergoing RIRS with the data of a group of patients from 18 and < 80 years. Perioperative outcomes, complications and emergency department visits were compared between two groups.

RESULTS

A total of 173 patients were included in the study. Mean age was 44 (27-79) and 81 years-old (80-94), for younger and elderly group, respectively. Elderly patients had higher ASA scores (≥ 3) (28.6% vs 75.8%; p = 0.0001) and Charlson comorbidity index (1.99 vs 7.86; p = 0.0001), more diabetes (p = 0.006) and respiratory comorbidities (p = 0.002). No statistical difference was found between two groups in stone size (p = 0.614) and number (p = 0.152). Operative time (74.48 vs 102.96 min; p = 0.0001) and duration of hospitalisation (1.7 vs 2.9 days; p = 0.001) were longer for the elderly. Intraoperative complication rate did not show differences between the two groups (p = 0.166). Postoperative complications rates were similar between the cohorts (7.7% vs 9.5%; p = 0.682). The success rates were 67.5% in the younger group and 71.4% in the elderly group (p = 0.584). No difference was seen in stone recurrence (p = 0.73). A higher rate of visits to the emergency department was found in younger cohort (23.6% vs 11.6%; p = 0.046), mostly duo to stent-related symptoms.

CONCLUSIONS

Despite the higher rate of comorbidity in the elderly group, RIRS was a safe procedure with similar complication rate and outcomes at an expense of higher operative time and hospital stay.

Safety and efficacy of retrograde intrarenal surgery in geriatric patients by age groups

PURPOSE

To evaluate the effects of aging on the success rate of retrograde intrarenal surgery (RIRS) and the development of medical and surgical complications by dividing geriatric patients into subgroups based on their chronological age.

METHOD

Data of the patients who underwent RIRS due to kidney stones at our clinic between June 2014 and January 2020 were retrospectively reviewed. Patients were divided into three groups based on age: 65-74 years (Group 1), 75-84 years (Group 2), and ≥ 85 years (Group 3). The comorbid diseases of patients were evaluated using the Charlson Comorbidity Index (CCI), total Cumulative Illness Rating Scale for Geriatrics (CIRS-G) score, and CIRS severity index (CIRS-G SI). RIRS success rates and complications were evaluated based on age groups.

RESULTS

A total of 336 patients were included in the study. The mean age of the patients was 72.7 ± 6.59 years. Stone-free rate was 81.5% in patients aged > 65 years and did not change with age. The modified Clavien-Dindo grade I/II complication rates for surgical complications were similar in all three groups (p = 0.818). In the evaluation of ROC analysis for medical complications, it was observed that the cut-off values were 76.5 years, CIRS-G score of 4.5, CCI score of 2.5, and CIRS-SI score of 1.18 (p < 0.001).

CONCLUSION

RIRS is an effective and safe treatment option for kidney and proximal ureteral stones in geriatric patients. Although there is an increase in medical complications post-RIRS with aging, surgical complications and stone-free rates remain unchanged.

Surgical management of urolithiasis in octogenarians

Objective:

The objective of this study was to report the outcomes of octogenarians undergoing surgical treatment for urolithiasis.

Materials and methods:

We performed a retrospective review of patients aged over 80 years who underwent surgical management for urolithiasis over 8.5 years. Data was collected for patient demographics, procedure, stone size, position, composition and clearance, urine cultures, complications and length of stay.

Results:

Sixty patients had 111 surgical procedures: 89 elective procedures (80.2%) and 22 emergency procedures (19.8%). Median age was 83 years (81–85), ASA grade 3 and stone size 8 mm (6–10). Clinical presentation was varied, with only 17 patients (28.3%) presenting with ureteric colic/flank pain. Ureterorenoscopy was performed in 74 procedures (66.7%). A ureteric stent was left in 91 procedures (82.0%). The median length of stay for the emergency patients was 6 nights (3–9.5 nights) and for the elective patients was 1 night (1–3 nights). The complication rate varied depending on the primary procedure performed. The overall complication rate was 19.8%: three (2.7%) Clavien I (urinary retention); 11 (9.9%) Clavien II (blood transfusion/urinary tract infection/urosepsis); two (1.8%) Clavien IIIb (stent insertion/bleeding); three (2.7%) Clavien IV (urosepsis) and three (2.7%) Clavien V (two patients urosepsis and one patient pneumonia). The stone-free rate was 68.3%.

Conclusion:

Octogenarian patients with urolithiasis have a variable presentation, and in patients with sepsis of unknown origin urolithiasis should be considered. We demonstrate that surgical treatment, in particular ureterorenoscopy, can be safely and effectively performed in octogenarians with appropriate surgical planning. Level of evidence: 4 Case series

Is the Efficacy and Safety of Retrograde Flexible Ureteroscopy in the Elderly Population Different from Non-elderly Adults?

Background and objectives The population of elderly adults is increasing globally, and due to metabolic changes related to advanced age, many elderly adults experience kidney stones. Flexible ureteroscopy (f-URS) is a minimally invasive procedure to treat kidney stones, but it is not free of complications. The goals of this study were to analyze the efficacy and safety of f-URS in the management of kidney stones in patients aged ≥60 years and compare the outcomes of this surgery with the outcomes of the same surgery in a younger population. Materials and methods We retrospectively reviewed patient data from 1750 patients who met our inclusion criteria and received f-URS at the urology clinic of our hospital from 2012 to 2017. Patients were assigned into two groups: those aged ≥60 years (Group 1, n=291) and those aged 19-59 years (Group 2, n=1459). The perioperative results were evaluated comparatively. We performed multivariable analyses for factors predicting complications. Results When we compared the groups on demographic attributes, we noted statistically significant differences in gender, body mass index (BMI), and American Society of Anesthesiologists scores. Stone size and operation time were higher in the ≥60-year age group (Group 1). Other stone characteristics and operative features were similar. Stone-free rates (SFR) after the first procedure were 88.0% in Group 1 and 89.2% in Group 2. SFR and success rates at three months were similar for both groups. The complication rates were similar, and multivariable regression analysis revealed the most important factor affecting the complications was the presence of residual stones in both groups. The second most important factor affecting the complication was the operation time in Group 1 and the number of stones in Group 2. Conclusion In our study, there were no significant differences in terms of results and complications among elderly and young patients after f-URS except for the duration of the operation. The prolongation of operation time results in worse outcomes in terms of perioperative complications in patients aged ≥60 years. f-URS is a relatively safe and efficient procedure, with a small risk of minor complications even in the elderly population, with increased comorbidity.

Ureteroscopy and stone treatment in the elderly (≥70 years): prospective outcomes over 5- years with a review of literature

Objective:

To assess outcomes of ureteroscopy for treatment of stone disease in the elderly. Ureteroscopy (URS) is an increasingly popular treatment modality for urolithiasis and its applications are ever expanding with the development of newer technologies. Its feasibility and outcomes within the elderly population to our knowledge remain under-reported.

Materials and Methods:

We examined the patient demographics and surgical outcomes from our prospective database for patients ≥70 years who underwent URS for urolithiasis, in a 5-year period between March 2012 and December 2016.

Results:

A total of 110 consecutive patients underwent 121 procedures (1.1 procedure/patient) with a mean age of 77.2 years (range: 70-91 years). Stone location was in the kidney/ pelviureteric junction (PUJ) in 29%, ureter in 37% and in multiple locations in 34%. The initial and final stone free rate (SFR) was 88% and 97% respectively. While 73% were done as true day case procedures, 89% patients were discharged within 24 hours. Eleven patients (9%) underwent complications of which 10 were Clavien I/II including acute urinary retention, urinary tract infection, stent symptoms and pneumonia. One patient underwent Clavien IV complication where they needed intensive care unit admission for urosepsis but fully recovered and were discharged home subsequently.

Conclusion:

Ureteroscopy is a safe and effective method of managing urolithiasis in elderly patients. Although most patients are discharged within 24-hours, consideration needs to be made for patients where social circumstances can impact their discharge planning.