Retrograde intrarenal stone surgery for extracorporeal shock-wave lithotripsy-resistant kidney stones

International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

Comparison of a single-use, digital flexible ureteroscope with a reusable, fiberoptic ureteroscope for management of patients with urolithiasis

OBJECTIVES

Ureteroscopy is one of the commonest procedures performed to manage urolithiasis. Flexible ureteroscopy has been traditionally based on reusable, fiber-optic ureteroscopes. Technology advancements permitted the development of single-use scopes with digital image. The aim of this study is to compare efficacy and safety between a reusable, fiberoptic ureteroscope with a single-use, digital scope.

PATIENTS AND METHODS

We collected data based on chart review from a prospectively collected database on a tertiary, high-volume hospital in Greece. Baseline, perioperative and postoperative data were gathered and analyzed. Chi-square and Fisher's exact test was used to compare qualitative data and unpaired t-test for continuous data, with a statistical significance set at a = 0.05.

RESULTS

40 patients underwent flexible ureteroscopy with a single- use digital scope, while 37 with the reusable scope. The two groups were matched regarding baseline characteristics and stone-related parameters. After data analysis, a shorter operative time in favor of single-use flexible ureteroscope was detected (45 vs 65 min, p = 0.001), while safety was also in favor of this type of scope with a significantly higher immediate stonefree rate (70% vs 43%, p = 0.005). Overall complications did not differ between the two groups, although a lower sepsis rate was detected in patients treated with single-use scope.

CONCLUSIONS

Our findings indicate that single-use, digital ureteroscopes are a viable alternative for flexible ureteroscopy and management of urolithiasis, especially in centers with deficient facilities for sterilization and ensured funds for more expensive reusable scopes.

When is the best time to perform external physical vibration lithecbole (EPVL) after retrograde intrarenal surgery (RIRS): a multi-center study based on randomized controlled trials

To determine the best time to perform EPVL treatment by evaluating the efficacy and safety of active stone extraction in treating residual fragments at different time points after RIRS. All participants had renal or upper ureteral stones preoperatively and still had residual stones after receiving RIRS. They were prospectively randomized into four groups: patients in group A received EPVL 3 days after RIRS; patients in group B received EPVL 7 days after RIRS; patients in group C received EPVL 14 days after RIRS; patients in group D did not receive EPVL after RIRS. Follow-up examinations were performed on all participants. The results, including stone size and location, stone-free rate (SFR) and complications, were compared among the groups. There were 176 patients in total. The SFR in groups A, B, C and D were 62.22%, 40.91%, 14.28% and 11.11%, respectively, 7 days after RIRS. At 14 days after RIRS, the SFR was 80%, 59.09%, 42.86% and 26.67% in groups A, B, C and D, respectively. At 28 days after RIRS, the SFR was 91.11%, 84.09%, 76.19% and 51.11% in groups A, B, C and D, respectively. Group A had the highest SFR from 7 to 28 days, and group C had a higher SFR at 28 days after RIRS than group D (P < 0.05). The side effects were less in groups A and B than in group D 28 days after RIRS (P < 0.05). We recommended that the best time to perform EPVL is 3 days after RIRS, because it could achieve a high SFR at any point in time and reduced complications.

Management behaviors of the urology practitioners to the small lower calyceal stones: the results of a web-based survey

Lower pole calyceal stones (LPS) represent lower spontaneous passage rates and, therefore, require several interventional treatment approaches. The aim of this survey study was to investigate the attitudes of the urology practitioners and the factors affecting their decision making in the management of small asymptomatic LPS. A total of 149 urologists participated to the study via email through the internet-based website. Participating urologists were asked to complete a 29-question survey including personal and academic data, level of surgical experience, available equipment for interventional approaches, which treatment do they prefer for small LPS (≥5 mm and <1 cm), and factors affecting their treatment decision. All data were analyzed to make inferences related with treatment decision and factors affecting decision-making. Mean participant age was 41.57 (26-62) years. The most preferred approach was observation/medical treatment option (52.3 %), subsequently SWL (25.5 %), RIRS (16.1 %), miniPNL (5.4 %) and standard PNL (0.7 %) were chosen by the participants. On the other side, SWL and medical treatment were at the forefront (52 and 16.1 %) among children. In the multivariate analysis of participants' age, academic status, surgical experience and institution, none was significantly associated with treatment decision-making (p > 0.05). The most important factors associated with decision making were calyceal dilatation (85.9 %) and patient preferences (81.2 %). The other factors effecting treatment decision were reported to be recurrent disease (70.5 %), the duration of the stone (74.5 %), patient age (95.3 %), current guidelines (87.9 %), stone density (50.3 %), body mass index (BMI) (73.8 %) and other morbid diseases (91.9 %). Our surveys' greatest value is in demonstrating the preferred treatment options and factors effecting decision-making in the treatment of LPS. The most preferred option in our population was follow-up and medical treatment. The most influencing factors on decision-making were age, patients' preferences, presence of calyceal dilatation, body mass index, comorbid conditions, available options for stone treatment and the surgeon's experience on the existing opportunities.

Ureteroscopy in proximal ureteral stones after shock wave lithotripsy failure: Is it safe and efficient or dangerous?

INTRODUCTION

We assessed the effectiveness of ureteroscopy (URS) in proximal ureteral stones performed after shock wave lithotripsy (SWL) failure, and determined outcomes in terms of success rate, complications, and operation time.

METHODS

We analyzed data of patients with previous unsuccessful SWL (Group I) and the ones that did not have SWL or URS before (Group II) for proximal ureteral stones between December 2007 and August 2014. Group I included 346 patients who underwent complementary URS and Group II 209 patients who underwent primary URS. Success rates, operation time and complications were compared between groups.

RESULTS

Success rates of complementary and primary URS were 78.9% and 80.9%, respectively. The difference in success rates was not statistically significant between groups (p = 0.57). The complication rates of complementary URS was 12.1%, and 9.5% in primary URS (p = 0.49). No statistically significant differences were noted in terms of gender, age, stone size and side, or lithotripter type between groups. The mean operation time and need for balloon dilatation were higher in complementary URS group compared to the primary URS group, and the difference was statistically significant (p < 0.05).

CONCLUSIONS

Complementary URS may be used safely after SWL failure in proximal ureteral stones. Its success rate and morbidities are similar to primary URS, except for longer operation time and an increased need for balloon dilatation.

Retrograde Intrarenal Surgery in Patients Who Previously Underwent Open Renal Stone Surgery

Purpose. To ascertain whether retrograde intrarenal surgery (RIRS) is as effective in patients treated previously with open renal stone surgery (ORSS) on the same kidney as in patients with no previous ORSS. Methods. There were 32 patients with renal stones who had previous ORSS and were treated with RIRS in the study group (Group 1). A total of 38 patients with renal stones who had no previous ORSS and were treated with RIRS were selected as the control group (Group 2). Recorded data regarding preoperative characteristics of the patients, stone properties, surgical parameters, outcomes, SFRs (no fragments or small fragments <4 mm), and complications between groups were compared. Results. Mean age, mean BMI, mean hospital stay, and mean operative time were not statistically different between groups. Mean stone size (10.1 ± 5.6 versus 10.3 ± 4.2; p = 0.551) and mean stone burden (25.4 ± 14.7 versus 23.5 ± 9.9; p = 0.504) were also similar between groups. After the second procedures, SFRs were 100% and 95% in groups 1 and 2, respectively (p = 0.496). No major perioperative complications were seen. Conclusion. RIRS can be safely and effectively performed with acceptable complication rates in patients treated previously with ORSS as in patients with no previous ORSS.

Outcomes of Flexible Ureterorenoscopy for Solitary Renal Stones in the CROES URS Global Study

PURPOSE

We determined the efficacy and safety of flexible ureterorenoscopy for single intrarenal calculi and further stratified efficacy by stone burden.

MATERIALS AND METHODS

CROES collected prospective data on consecutive patients with urinary stones treated with ureterorenoscopy at 114 centers worldwide for 1 year. Only patients who underwent flexible ureterorenoscopy for a solitary renal stone were included in study. Preoperative and intraoperative characteristics, and postoperative outcomes were evaluated. Relationships between stone size and the stone-free rate, operative time, complications, hospital stay and need for re-treatment were determined.

RESULTS

A total of 1,210 patients with a solitary kidney stone less than 10 (52.2%), 10 to 20 (43.2%) and greater than 20 mm (4.6%) were treated with flexible ureterorenoscopy. The stone-free rate negatively correlated with stone size when adjusted for body mass index. Operative time positively correlated with stone size when adjusted for body mass index. The single session stone-free rate was 90% and 80% for stones less than 10 and less than 15 mm, respectively. Patients with stones greater than 20 mm achieved a 30% stone-free rate, more often needed re-treatment and were more often rehospitalized. There was no difference in the overall complication rate by stone size. However, patients with a stone greater than 20 mm showed a higher probability of fever after flexible ureterorenoscopy than those with a smaller stone.

CONCLUSIONS

Our data indicate that flexible ureterorenoscopy for a single intrarenal stone is a safe procedure. Best results after single session flexible ureterorenoscopy were obtained for stones less than 15 mm.

Effectiveness of Flexible Ureterorenoscopy and Laser Lithotripsy for Multiple Unilateral Intrarenal Stones Smaller Than 2 cm

Purpose. To evaluate the safety and efficacy of RIRS for the treatment of multiple unilateral intrarenal stones smaller than 20 mm. Methods. Between March 2007 and April 2013, patients with multiple intrarenal stones smaller than 20 mm were treated with RIRS and evaluated retrospectively. Each patient was evaluated for stone number, stone burden (cumulative stone length), operative time, SFRs, and complications. Results. 173 intrarenal stones in 48 patients were included. Mean age, mean number of stones per patient, mean stone burden, and mean operative time were 40.2 ± 10.9 years (23–63), 3.6 ± 3.0 (2–18), 22.2 ± 8.4 mm (12–45), and 60.3 ± 22.0 minutes (30–130), respectively. The overall SFR was 91.7%. SFRs for patients with a stone burden less and greater than 20 mm were 100% (23/23) and 84% (21/25), respectively (χ² = 26.022, P < 0.001). Complications occurred in six (12.5%–6/48) patients, including urinary tract infection or high-grade fever >38.5°C in three cases, prolonged hematuria in two cases, and ureteral perforation in one case, all of whom were treated conservatively. No major complications occurred. Conclusions. RIRS is an effective treatment option in patients with multiple unilateral intrarenal stones especially when the total stone burden is less than 20 mm.

Does previous failed ESWL have a negative impact of on the outcome of ureterorenoscopy? A matched pair analysis

This study aims to evaluate the outcome of ureteroscopy/ureterorenoscopy (URS) as a salvage procedure for stones resistant to extracorporeal shock wave lithotripsy (ESWL). Between January 2009 and January 2012, 313 patients with upper tract lithiasis were treated by URS. Among them, 87 (27.8 %) had undergone URS after prior ESWL failed to achieve stone clearance (Salvage group). These patients were matched with a group of patients who underwent URS as first-line modality (Primary group). Stone-free rates and adjuvant procedures represented the primary points for comparison. Secondary points for comparison included complications, procedure duration, total laser energy used and length of hospitalization. Matching was possible in all cases. Stone clearance rates were 73.6 and 82.8 % for the Salvage and Primary group, respectively. The difference in stone clearance rates between the two groups was not statistically significant (p = 0.186). A total of 11 patients (12.6 %) in the Primary group and 18 patients (20.7 %) in the Salvage group underwent an adjuvant procedure (p = 0.154). No statistically significant differences were noted in terms of complications, procedure duration and length of hospitalization. In the Primary group, the laser energy used for stone fragmentation was higher (p = 0.043). The rate of ureteric stenting at the end of the procedure was higher for the Salvage group (p = 0.030). Previous failed ESWL is not a predictor for unfavorable outcome of URS. Salvage URS is associated, however, with an increased need for ureteric stenting at the end of the procedure.

Percutaneous nephrolithotomy for renal stones following failed extracorporeal shockwave lithotripsy: different performances and morbidities

The purpose of this study is to summarize the results of percutaneous nephrolithotomy (PCNL) for renal stones following failed extracorporeal shockwave lithotripsy (SWL), and to investigate the effect of previous SWL on the performances and morbidities of subsequent PCNL. Sixty-two patients with a history of failed SWL who underwent PCNL on the same kidney (group 1) were compared to 273 patients who had received PCNL as first treatment choice (group 2). Patient demographics, stone characteristics, operative findings, and complications were documented and compared. Groups 1 and 2 had similar patient demographics and stone characteristics. Mean time to establish access was comparable in both groups (10.5 ± 4.2 vs. 9.6 ± 4.5 min, p = 0.894). Time required to remove stones and total operative time were longer in group 1 (71.5 ± 10.3 vs. 62.3 ± 8.6 min, p = 0.011 and 95.8 ± 12.0 vs. 80.6 ± 13.2 min., p = 0.018, respectively). Group 1 had lower clearance rate compared to group 2 (83.9 vs. 93.4 %, p = 0.021), while postoperative complications were similar in both groups. Scattered stone fragments buried within the tissues made the procedure more difficult for stone fragmenting and extracting, which lead to longer operative time and inferior stone free rate. However, the PCNL procedure was safe and effective in patients with failed SWL. The risk of complications was similar and clearance rate was encouraging.

Urinary tract stone disease: are all problems solved?

During the past four decades there have been dramatic developments in the methods used for active stone removal from the urinary tract, and the need for open surgery has been almost entirely replaced by extracorporeal shockwave lithotripsy, percutaneous surgery, ureteroscopy and retrograde intrarenal surgery. Residual fragments and the pronounced risk of recurrent stone formation remain important problems for the future development of urolithology and for the optimal low-risk management of this large group of patients. It is emphasized that all aspects of the care of patients with stone disease are the responsibility of the urologist.

Ureteroscopic management with laser lithotripsy of renal pelvic stones

BACKGROUND AND PURPOSE

The development of semirigid and flexible ureteroscopes has permitted easier access to calculi throughout the urinary tract. We compared the use of semirigid and flexible ureteroscopy for the management of shockwave lithotripsy-refractory, isolated renal pelvic calculi by evaluating stone-free rates, operating room times, and associated complications.

PATIENTS AND METHODS

Ureteroscopic stone treatment was attempted in 47 patients with isolated renal pelvic stones between November 2008 and December 2010. The procedures were performed under general anesthesia. Semirigid ureteroscopy was routinely performed in all patients. If the stones were accessible in the renal pelvis with the semirigid ureteroscope (S-URS), they were then treated with the holmium:yttrium-aluminum-garnet (Ho:YAG) laser through S-URS under direct vision. If the stones were not accessible, flexible ureteroscopy was then performed. Preoperative, operative, and postoperative data were retrospectively analyzed.

RESULTS

In 25 of 47 patients, renal pelvic stones were accessible with S-URS, and the stones were fragmented with the Ho:YAG laser using S-URS. In the remaining 22 patients, the stones were accessed with the flexible ureteroscope (F-URS), and the fragmentation of stones was performed with the Ho:YAG laser using the F-URS. There were no significant differences in age, body mass index, grade of hydronephrosis, mean stone size, and stone laterality among the two groups. The mean operative times were 71.90 ± 17.90 minutes in the S-URS group and 93.41 ± 18.56 minutes in the F-URS group (P=0.001). The stone-free rates at postoperative day 1 and at the 1 month follow-up were 72% and 76% in the S-URS group and 81.8% and 86.4% in the F-URS group, respectively (P=0.861 and P=0.368). We found no significant differences among groups with regard to stone-free rates, complication rates, and hospital lengths of stay.

CONCLUSIONS

Although it is well known that flexible ureteroscopy permits a detailed caliceal examination and therapeutic interventions, semirigid ureteroscopy is also often another sufficient means of reaching the renal pelvis in selected patients.

Ureteroscopic retrograde intrarenal surgery after previous open renal stone surgery: initial experience

The management of renal calculi following previous open surgery represents a challenge for urologists. The aim of this study is to evaluate the outcomes and safety of ureteroscopic laser retrograde intrarenal surgery (RIRS) for renal calculi following prior open renal surgery. The charts of 53 patients who underwent RIRS for renal calculi following prior open surgery for urolithiasis were reviewed. Both flexible and semi-rigid ureteroscopes were utilized together with holmium: YAG laser for stone disintegration. Intravenous urography, computed tomography (CT) and ultrasound were used to evaluate the patient, perioperatively. Stone size ranged from 5 to 32 mm (mean 14.3 mm). The mean operative time was 86 min (20-130). The overall stone-free rate was 92.4%. The overall stone-free rates after one and two-procedures were 79.2% (42 cases) and 92.4% (49 cases), respectively. Four patients (7.5%) had larger residual fragments, 2 (3.8%) of them underwent SWL, and 2 (3.8%) cases were followed up conservatively. Major complications were reported in two patients (3.8%). Stone analysis revealed calcium oxalate in 39 patients, uric acid in 5, calcium phosphate in 4, struvite in 3, and cystine in 2 cases. Ureteroscopic retrograde intrarenal surgery for renal calculi following prior open renal surgery was a minimally invasive, safe procedure with a high success rate. It is a viable alternative for PNL in managing recurrent renal calculi efficiently.

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.

Treatment outcomes of retrograde intrarenal surgery for renal stones and predictive factors of stone-free

Purpose

The aim of this study was to evaluate the efficacy and safety of retrograde intrarenal surgery (RIRS) for the treatment of renal stones and to analyze the predictive factors for stone-free.

Materials and Methods

We retrospectively reviewed the records of patients who underwent RIRS for renal stones from January 2000 to July 2009. We identified 66 RIRSs (63 patients with 3 bilateral renal stones) and collected data. Stone-free and success were respectively defined as no visible stones and clinically insignificant residual stones less than 3 mm on postoperative imaging; predictive factors for stone-free were evaluated.

Results

Of the 66 renal stones, 18 stones (27.3%) were located in the upper pole or midpole or renal pelvis and 48 (72.7%) in the lower pole with or without others, respectively. The mean cumulative stone burden was 168.9±392.5 mm². The immediate postoperative stone-free rate was 69.7%, and it increased to 72.7% at 1 month after surgery. The success rate was 80.3% both immediately after the operation and 1 month later. In the multivariate analysis, stone location except at the lower pole (p=0.049) and small cumulative stone burden (p=0.002) were significantly favorable predictive factors for the immediate postoperative stone-free rate. The overall complication rate was 6%.

Conclusions

RIRS is a safe and effective treatment for renal stones. The stone-free rate of RIRS was particularly high for renal stones with a small burden, except for those located in the lower pole. RIRS could be considered in selective patients with renal stones.

Failure after shockwave lithotripsy: is outcome machine dependent?

AIM

To investigate the issue of shockwave lithotripsy failure by studying the effect of machine crossover to the Technomed Sonolith Vision (TSV) lithotriptor in patients with previously unsuccessfully treated renal stones with the Dornier Compact Delta (DCD). Records were examined for the period between 1998 and 2006. Parameters analysed were: size, multiple/single stones, location, treatments/stone.

RESULTS

Seventy-six patients fulfilled the inclusion criteria. Following lithotripsy with the TSV, the stone-free rate (SFR) at 3 months was 56.7%, and the success rate (stone-free and fragments < or = 4 mm, SR) 86.7%. Twenty-two patients had multiple stones and the majority of the stones were located in the lower calyx (59.2%). Mean size was 8.9 mm prior to treatment with the TSV machine (10.2 mm for DCD). Further analysis followed in a subgroup of 42 patients of the same stone size (+/-2 mm) before and after DCD sessions. Mean stone size was 7 mm. The SFR was 61.9% (62.9% vs. 40.9% for single and multiple stones), and the SR was 88.1%. No difference in SFR was found for single or multiple stones in any of the two groups.

CONCLUSIONS

The term 'extracorporeal shockwave lithotripsy (ESWL)-resistant stones' needs to be re-examined, as treatment with a different lithotriptor was successful in a group of stones where another machine had failed. Lithotripters with different shock wave characteristics may result in difference in the results of ESWL. Future research in ESWL should focus on stone characteristics and development of machines with the ability to adapt to specific stone features.

Lower calyceal occlusion by autologous blood clot to prevent stone fragment reaccumulation after retrograde intra-renal surgery for lower calyceal stones: first experience of a new technique

PURPOSE

We tested the hypothesis that lower calyceal (LC) autologous blood clot (ABC) occlusion, after retrograde intra-renal surgery (RIRS) may prevent LC fragment reaccumulation where all fragments cannot be directly removed.

METHODS

Over two years, patients with LC stones >6 mm <2 cm, that had presented de-novo or failed primary SWL or PNL elsewhere, were treated with RIRS. After intra-renal relocation into a favorable lie, stones were fragmented with Holmium laser energy to <3 mm, suitable for spontaneous passage. The LC was filled with 5-10 cc venous autologous blood with the patient in reverse Trendelenberg, leaving the blood to clot. After confirmatory pyelogram a DJ stent was placed. Ultrasound and KUB at 3 months assessed stone free rate.

RESULTS

This technique was tested in 35 patients with LC calculi (16 as primary treatment, and 19 as salvage for residual fragments post SWL or PNL). Nine salvage patients had indwelling DJ stents (three significantly encrusted at RIRS). Nine unstented patients had upper ureteral tortuosities or narrowing limiting multiple instrument passes for stone removal. Median maximum stone dimension was 1.2 cm. All were successfully relocated & fragmented. A Nitinol basket was required for stone relocation in 60%. All but one occlusion procedures succeeded at the first attempt. None required re-admission for clot colic. Only 8.6% required more than overnight hospital stay. Three and six month stone free rates were 94% and 97% respectively.

CONCLUSIONS

The simple LC autologous blood clot occlusion technique after RIRS, for difficult LC stones, validates our hypothesis and results in excellent stone free rates, while minimizing ureteral trauma from multiple instrument passages needed for active fragment removal. This study supports the need for multi-center experience of this technique to validate our results.