Comparison of miniaturized percutaneous nephrolithotomy and flexible ureterorenoscopy for moderate size renal stones in elderly patients

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.

One-stage efficacy of single tract minimally invasive ECIRS in the improved prone frog split-leg position for staghorn stones

OBJECTIVE

To explore the feasibility, safety, and effectiveness of single tract minimally invasive endoscopic combined intrarenal surgery (stmECIRS) in the improved prone frog split-leg position for staghorn stones.

METHOD

A total of 83 patients with staghorn stones were retrospectively reviewed between January 2018 and June 2021. According to surgical procedure and position, patients were divided into a group of single tract minimally invasive percutaneous nephroscopy (stmPNL) in the prone position and a group of stmECIRS in the improved prone frog split-leg position (turned to the prone position after preset the flexible ureteroscope sheath in lithotomy position, meanwhile, bend both hips and knees to be frog abduction). Demographic characteristics, laboratory tests, stone characters, surgical information, stone-free rate (SFR), and perioperative complications were observed and analyzed.

RESULTS

There were no significant differences in demographic characteristics, changes level of Scr and Hb, stone size, radiation density, length of hospital stay, and operation time between the two groups. One-stage SFR in the stmECIRS group was significantly higher than that in the stmPNL group (84.4% vs. 57.9%) (P = 0.007), only 2 patients required blood transfusion after surgery (P = 0.862), and other postoperative complications were not statistically significant (P = 0.345).

CONCLUSIONS

StmECIRS in improved prone frog split-leg position has a higher one-stage SFR than stmPNL for staghorn renal stones, and without complications increased, which is a safe, efficient and feasible treatment.

The comparison of perioperative outcomes between percutaneous nephrolithotomy and retrograde intrarenal surgery in elderly patients

OBJECTIVES

In this study, we aimed to compare the outcomes and complication rates of percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) in elderly patients.

MATERIALS AND METHODS

Between April 2011 and January 2020, patients who underwent PCNL and RIRS for renal stone in elderly patients were retrospectively evaluated. The two groups' perioperative values, stone-free rates and complication rates were compared. Post-operative complications were noted according to the Clavien scoring system.

RESULTS

There were 89 and 72 patients in the PCNL and RIRS group respectively. The median age was 67 years in both the groups (P = .192). The stone size were 22.2 ± 3.5 mm and 19.9 ± 7.1 mm in the PCNL and RIRS group, respectively (P = .082). Stone-free rates were significantly higher in PCNL group (P = .021, P = .034). Also we found that overall complication and major complication rates were significantly higher in PCNL group (P = .016, P = .029).

CONCLUSION

Despite there was higher stone clearance in PCNL, the complication rates were higher compared with RIRS. So RIRS might be a safe alternative treatment method to PCNL in older patients.

Comparison of retrograde ureterorenoscopy (URS) and percutaneous anterograde ureteroscopy for removal of impacted upper ureteral stones >10mm in the elderly population

PURPOSE

We aimed to compare the success and complication rates of the anterograde and retrograde Ureterorenoscopy (URS) for impacted upper ureteral stones in patients > 65 years of age.

MATERIALS AND METHODS

Data of 146 patients >65 years of age and underwent anterograde URS (n=68) in supine position or retrograde URS (n=78) for upper ureteral impacted stones>10 mm between January 2014 and September 2018 were collected prospectively. The groups were compared for success and complication rates, duration of operation, hospital stay, and ancillary procedures.

RESULTS

Anterograde and retrograde URS groups were similar for demographic and stone related characteristics. The success rate of the anterograde URS group was significantly higher than the retrograde URS group (97.1% vs. 78.2%, p=0.0007). The complication rates were similar for the two groups (p=0.86). Clavien grade I and II complications were observed in 3 patients in each group. The mean hemoglobin drop was 0.5 g/dL in the anterograde URS group and blood transfusion was not performed in any of the patients. The mean duration of operation was 41.2±12.5 minutes in the mini-PNL group and 59.6±15.1 minutes in the RIRS group and the difference was statistically significant (p=0.02). The median duration of hospitalization was 1 day for both groups.

CONCLUSIONS

Performing anterograde URS in supine position provided better success rates and similar complication rates compared to retrograde URS. Based on these results anterograde URS shall be considered as one of the primary treatment options for management of impacted upper ureteral stones in the elderly population.

Percutaneous nephrolithotomy versus flexible ureteroscopic lithotripsy in the treatment of upper urinary tract stones: a meta-analysis comparing clinical efficacy and safety

BACKGROUND

Upper urinary tract stones is the most common diseases in urology. Percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (fURL) are common treatment, but both their efficacy and safety are controversial. Thus we aim to evaluate the efficacy and safety of PCNL and fURL in the treatment of upper urinary tract stones, providing a reference for clinical work.

METHODS

PubMed, Web of Science, Embase and CNKI were searched through Apr. 1, 2019 to identify eligible studies. Data were analyzed by using RevMan 5.3 and Stata 12.0 software. Pooled relative risks (RRs) or weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated using fixed or random effects methods. Publication bias and sensitivity analysis were performed.

RESULTS

Four randomized controlled trials (RCTs), fifteen cohort studies involving 1822 patients were included. Stone-free rate of PCNL was significantly high than that of fURL (RR: 1.07; 95% CI: 1.03, 1.12; P = 0.0004). The decline of hemoglobin in PCNL was significantly high than that of fURL (WMD: 1.07; 95% CI: 0.54, 1.61; P < 0.0001). The number of blood transfusion was significantly greater in the PCNL compared to the fURL (RR: 5.04; 95% CI: 1.78, 14.24; P = 0.002). The incidence of postoperative bleeding or hematuria showed greater significantly difference in the PCNL compared to the fURL (RR: 2.72; 95% CI: 1.55, 4.75; P = 0.0005). Operation time, fever, infection, perforation, requiring drug analgesia was not significantly different between two surgical procedures.

CONCLUSIONS

In the treatment of upper urinary tract stones, the stones clearance rate of PCNL is higher than fURL, and the safety of fURL is higher than PCNL.

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.

Multiple renal ruptures after flexible ureteroscopic lithotripsy with holmium laser

The authors present a case report of multiple renal ruptures after flexible ureteroscopic lithotripsy (FURL) with holmium laser. Multiple renal ruptures following flexible ureterorenoscopy have not been reported so far. The etiology remains unclear. We like to share this case to make urologists aware of this unusual complication and discuss possible causes and therapeutic approaches.

A retrospective study comparing super-mini percutaneous nephrolithotomy and flexible ureteroscopy for the treatment of 20-30 mm renal stones in obese patients

Objective

This study aimed to compare the efficacy and safety of Super-mini percutaneous nephrolithotomy (SMP) and flexible ureteroscopy (F-URS) in the treatment of 20–30 mm renal stones in obese patients.

Methods

We conducted a retrospective analysis of outcomes of patients who underwent SMP and F-URS to treat 20–30 mm renal stones from August 2017 to September 2018. Patients with BMI >30 kg/m² were enrolled into this study. Forty-eight patients underwent SMP, while 104 patients underwent F-URS by the same surgeon. The patients’ demographic data, stone characteristics, perioperative parameters and outcomes, complications, stone-free rate (SFR) and overall costs were retrospectively assessed.

Results

No significant differences were found between the two groups in terms of age, gender, BMI, operation side, stone size, number, locations, stone compositions and CT value. The mean operation time was significantly shorter in the SMP group (p < 0.001), while the F-URS group had significantly shorter postoperative stays (p < 0.001) and lower complication rates (p < 0.001). Both groups had similar SFR at a 3-month follow-up (p = 0.190), while the SMP group achieved significant higher SFR 3 days after the operation (p < 0.001). The SMP group had a significantly lower overall cost and fewer stage-2 procedures than the F-URS group.

Conclusion

SMP and F-URS are equally effective in obese patients with 20–30 mm renal stones. However, F-URS offers the advantage of a lower complication rate, while SMP performed better in terms of operation time, tubeless rate, stage-2 procedures and overall costs.

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

Treatment of Complex Renal Calculi by Digital Flexible Ureterorenoscopy Combined with Single-Tract Super-Mini Percutaneous Nephrolithotomy in Prone Position: A Retrospective Cohort Study

Background

Advances in percutaneous nephrolithotomy (PCNL) have resulted in smaller devices that cause less trauma and bleeding, while flexible ureterorenoscopy (f-URS) allows access to any calyces. These methods are often used in isolation, but used in combination they may improve treatment of complex renal calculi. This study assessed the effectiveness and complications of f-URS combined with super-mini-PCNL (SMP) to treat complex renal calculi.

Material/Methods

A retrospective cohort analysis was made of patients with unilateral complex renal stones treated between March 2013 and December 2016. Patients were grouped according to surgical procedure: SMP (SMP Group), f-URS holmium laser lithotripsy (f-URS Group), and combined SMP and f-URS (Combined Group). The postoperative complications and complete stone-free rate were analyzed and compared among the 3 groups.

Results

A total of 140 patients with complex renal stones were included: 40 patients in the SMP Group, 55 in the f-URS Group, and 45 in the Combined Group. The complete stone-free rate 3 days after the procedure was 77.5% in the SMP Group, 78.2% in the f-URS Group, and 97.8% in the Combined Group (p=0.010). The operation time, intraoperative blood loss, and hospitalization time of the Combined Group were all significantly lower than those in the SMP Group but higher than those in the f-URS Group. The follow-up was 9 months (range, 6–12 months). There were no medium-term complications reported.

Conclusions

SMP combined with f-URS holmium laser lithotripsy in the prone position is an effective treatment for complex renal calculi.