Removal of asymptomatic ipsilateral renal stones following rigid ureteroscopy for ureteral stones

The effect of Trendelenburg position on outcomes of retrograde intrarenal surgery for medium sized renal pelvis stones

Aim: To compare safety and efficiency between Trendelenburg position retrograde intrarenal surgery (tRIRS) and conventional position retrograde intrarenal surgery (cRIRS) in the management of renal pelvis stones 10-20 mm in size. Material and Method: From September 2018 to September 2019, the patients undergoing RIRS for single renal stones between 10-20 mm were included in the study prospectively. Patients were divided into two groups randomly. First group of patients were positioned completely parallel to the ground (cRIRS), second group were positioned with Trendelenburg (tRIRS). Success was evaluated at end of 3rd months by non-contrast enhanced tomography. Stones that smaller than 4 mm were accepted as clinical insignificant residual fragment. Complications was classified according to Clavien, class 2 or more complications were recorded. Results: Totally 100 patients were included to final analyze. Patients’ age, gender, stone side and mean stone surface area were similar between groups. Success rate was higher in tRIRS group (90% vs 72% p=0.022). Mean operation time was lower (41.8 vs 58.2 min. p

Removal of Small, Asymptomatic Kidney Stones and Incidence of Relapse

BACKGROUND

The benefits of removing small (≤6 mm), asymptomatic kidney stones endoscopically is unknown. Current guidelines leave such decisions to the urologist and the patient. A prospective study involving older, nonendoscopic technology and some retrospective studies favor observation. However, published data indicate that about half of small renal stones left in place at the time that larger stones were removed caused other symptomatic events within 5 years after surgery.

METHODS

We conducted a multicenter, randomized, controlled trial in which, during the endoscopic removal of ureteral or contralateral kidney stones, remaining small, asymptomatic stones were removed in 38 patients (treatment group) and were not removed in 35 patients (control group). The primary outcome was relapse as measured by future emergency department visits, surgeries, or growth of secondary stones.

RESULTS

After a mean follow-up of 4.2 years, the treatment group had a longer time to relapse than the control group (P<0.001 by log-rank test). The restricted mean (±SE) time to relapse was 75% longer in the treatment group than in the control group (1631.6±72.8 days vs. 934.2±121.8 days). The risk of relapse was 82% lower in the treatment group than the control group (hazard ratio, 0.18; 95% confidence interval, 0.07 to 0.44), with 16% of patients in the treatment group having a relapse as compared with 63% of those in the control group. Treatment added a median of 25.6 minutes (interquartile range, 18.5 to 35.2) to the surgery time. Five patients in the treatment group and four in the control group had emergency department visits within 2 weeks after surgery. Eight patients in the treatment group and 10 in the control group reported passing kidney stones.

CONCLUSIONS

The removal of small, asymptomatic kidney stones during surgery to remove ureteral or contralateral kidney stones resulted in a lower incidence of relapse than nonremoval and in a similar number of emergency department visits related to the surgery. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Veterans Affairs Puget Sound Health Care System; ClinicalTrials.gov number, NCT02210650.).

The effect of stone size on the results of extracorporeal shockwave lithotripsy versus semi-rigid ureteroscopic lithotripsy in the management of upper ureteric stones

Objectives

Patients and methods

Results

Conclusion

Decreased Recurrence of Urolithiasis After Simultaneous Ureteroscopic Surgery for Ureter and Ipsilateral Renal Calculi: Comparison to Shockwave Lithotripsy for Ureter Calculi Alone

OBJECTIVE

To compare follow-up outcomes of ureteroscopy (URS) and shockwave lithotripsy (SWL) for ureter calculi in the setting of asymptomatic renal calculi <15 mm.

METHODS

This study included 789 patients who underwent URS (n = 301) or SWL (n = 488) as primary treatment for ureter calculi and who had ipsilateral renal calculi <15 mm between January 2012 and December 2019. For the URS group, all renal calculi were simultaneously treated unless contraindicated. One-to-one matching was performed using the propensity score (PS).

RESULTS

After PS matching, analysis included 262 matched pairs of URS and SWL patients. The stone-free rate for ureter calculi without auxiliary procedure was 97.3% in the URS group and 93.9% in the SWL group. Any complication rates were 11.0% and 9.2% in the URS and SWL group, respectively; 1.1% of the URS patients experienced complications classified as Clavien-Dindo ≥IIIb. The estimated 2-year intervention-free survival was 88.1% in the URS group and 84.2% in the SWL group (P = 0.045). The estimated 2-year stone-event-free survival was 80.1% in the URS group and 71.0% in the SWL group (P = 0.009). Cox multivariate analysis showed that the hazard ratios of URS were 0.62 (P = 0.025) for surgical interventions and 0.64 (P = 0.008) for stone-related events after adjusting for baseline variables.

CONCLUSION

For patients with symptomatic ureter calculi and asymptomatic renal calculi <15 mm, URS with active treatment for renal calculi reduces future ipsilateral surgical intervention and stone-related events compared with SWL for ureter calculi.

Bilateral same-session ureterorenoscopy: A feasible approach to treat pan-urinary stone disease

Objectives

To assess treatment effectiveness and safety of bilateral same-session ureterorenoscopy (BSSU) for the management of stone disease involving the entire urinary system.

Patients and methods

We reviewed the records of 64 patients who underwent BSSU for the treatment of bilateral ureteric and/or kidney stones. Size, number, location per side, and the total burden of stones were recorded. Data on stenting, lithotripsy, and stone retrieval, and details of hospital stay and operation times were investigated. Treatment results were assessed using intraoperative findings and postoperative imaging. The outcome was considered successful in patients who were completely stone-free or who had only residual fragments of ≤2 mm.

Results

The outcome was successful in 82.8% of the patients who received BSSU (54.7% stone-free and 28.1% insignificant residual fragments). The success rate per renal unit was 89.8%. There were no adverse events in 73.4% of the patients. The most common intraoperative complication was mucosal injury (36%). The complications were Clavien-Dindo Grade I in 9.4% and Grade II in 7.8%. Grade IIIa and IIIb (9.4%) complications required re-treatments. Statistical evaluation showed no association between complication grades and stone, patient, or operation features. Stone burden had no negative impact on BSSU results. The presence of impacted proximal ureteric stones was significantly related to unsuccessful outcomes.

Conclusion

BSSU is safe and effective for the management of bilateral urolithiasis. BSSU can prevent recurrent surgeries, reduce overall hospital stay, and achieve a stone-free status and complication rates that are comparable to those of unilateral or staged bilateral procedures.

Combined ureterorenoscopy for ureteral and renal calculi is not associated with adverse outcomes

Introduction

We intended to evaluate the feasibility and effectiveness of the simultaneous rigid and flexible ureteroscopic treatment of symptomatic ureteral and ipsilateral small simultaneous calyceal stones. Outcomes of combined therapy were compared with monotherapy alone.

Material and methods

In this retrospective study, group 1 consisted of 45 patients with middle or lower ureteral and ipsilateral small simultaneous calyceal stones treated by combined therapy. Group 2 included 45 patients with middle or lower ureteral stones only and treated by monotherapy. Stone characteristics, operative time, hospital stay, stone free rates, and complications were compared between groups 1 and 2. Stone free status was defined as no fragments and/or the presence of asymptomatic fragments smaller than 4 mm.

Results

Mean BMI were 29.3 ±0.9 kg/m² and 27.6 ±0.6 kg/m² in groups 1 and 2, respectively. Mean ureteral stone size (7.6 ±0.4 mm vs. 8.0 ±0.4 mm, p = 0.261) and ureteral stone burden (56.0 ±5.5 mm²vs. 54.8 ±6.1 mm², p = 0.487) were similar between groups. Mean renal stone size and renal stone burden for group 1 were 7.1 ±0.8 mm and 83.7 ±11.3 mm². The mean operative time was significantly longer (for a mean of 32.5±1.2 minutes) for group 1 (p = 0.001). Ureteral stents were left in 38 (84.4%) and 19 (42.2%) patients in group 1 and group 2 (p = 0.001). Hospital stay and complication rates were similar between groups. SFRs were 100% for ureteral stones in both groups and 88.9% for renal stones within group 1.

Conclusions

Simultaneous ureteroscopic treatment of the ureteral and ipsilateral small calyceal stones prolongs operative time and increases use of ureteral stent without leaving any residual renal stones.

Ureteroscopic lithotripsy in Trendelenburg position for proximal ureteral calculi: a prospective, randomized, comparative study

PURPOSE

We conducted a prospective, randomized, comparative study to compare the clinical outcome between the Trendelenburg position ureteroscopic lithotripsy (tURSL) and the conventional position ureteroscopic lithotripsy (cURSL) for the management of single proximal ureteral stone.

METHODS

From January 2012 to September 2013, consecutive patients with single proximal ureteral calculi less than 2 cm and planned for ureteroscopic lithotripsy at our institution were enrolled in this study. The eligible patients were randomized into cURSL group and tURSL group according to sequence of random numbers generated by computer. In tURSL group, patients were turned into a Trendelenburg lithotomy position with head down 30° while the conventional lithotomy position was applied in cURSL group. URSL was performed using a 6/7.5F semi-rigid ureteroscope with holmium laser. When retropulsion occurred, the stones fragments were followed by semi-rigid ureteroscope up to the renal collecting system. The Olympus P5 flexible ureteroscope was used if there was any suspicion of stone migration into lower calices or incomplete stone fragmentation by semi-rigid ureteroscope. Patients' demographics between the two groups, perioperative course, clinical outcome and complication rates were compared. Data were analyzed using Chi-square test, Fisher's exact test or Student's t test. Binary logistic regression analysis was applied to estimate the effects of surgical position and stone size on stone migration.

RESULTS

A total of 355 cases were finally analyzed in this study (176 in cURSL group and 179 in tURSL group). The mean operative time was significantly prolonged in cURSL group than in tURSL group, while the stone-free rate (SFR) at 4 weeks was significantly higher in tURSL group. A statistically significant difference was found in stone migration rate between the two groups (26.7 vs. 43.6 %, P = 0.001). In the stone migration subsetting, less stones fragments were found to migrate into lower calices in tURSL stone migration subgroup (P = 0.000). Also, the flexible ureteroscope utilization as well as the operative time was significantly decreased in tURSL stone migration subgroup (25.5 vs. 72.3 %, P = 0.000), (44.96 ± 11.0 min vs. 59.17 ± 9.2 min, P = 0.000) with higher SFR after retrograde intrarenal surgery (RIRS) (96.2 vs. 74.5 %, P = 0.000).

CONCLUSION

The tURSL was safe and highly efficacious for the management of proximal ureteral calculus, especially in nonobese patient. Even with important stone migration risk, it rendered higher SFR and less operative time compared with cURSL. Moreover, less utilization of flexible ureteroscope and decreased deflection time in tURSL could potentially reduce the medical cost.

The impact of retrograde intrarenal surgery for asymptomatic renal stones in patients undergoing ureteroscopy for a symptomatic ureteral stone

BACKGROUND AND PURPOSE

In the era of rigid ureteroscopy (URS) for ureteral stones, asymptomatic renal stones were often left in place. With the advent of flexible URS, however, the treatment of such renal stones became an attractive option. Data are scarce regarding the impact of retrograde intrarenal surgery (RIRS) performed at the time of URS for a symptomatic ureteral stone in comparison with ureteral stone removal alone. The purpose of the study was to compare the outcomes of URS combined with RIRS with URS alone.

PATIENTS AND METHODS

A comparison between patients who underwent URS and RIRS (group A, n=47) and a matched control group of patients undergoing URS alone (group B, n=47) was performed. Matching was based on ureteral stone size and location, and preprocedural Double-J stent placement.

RESULTS

The median size of the largest ureteral stone in both groups was 8 mm with a mean total stone burden of 52.9 mm(2) (28.9) and 47 mm(2) (21.1) in groups A and B, respectively. Median renal stone size was 9 mm with a mean total stone burden of 84.1 mm(2) (40.3). Mean surgery time in groups A and B was 68 minutes (19.61) and 39 minutes (15.96), respectively (P<0.001). Median hospital stay was 1 day for both groups. The success rate for ureteral stone removal was 98% and 100% in groups A and B, respectively. Success rate for RIRS was 85% (40/47 cases). Hospitalization length and complications, mainly postoperative fever, did not differ significantly between the groups.

CONCLUSIONS

Managing asymptomatic renal stones at the time of URS for symptomatic ureteral stones significantly prolongs surgery duration but does not lengthen hospital stay, increase complications, or lower success rates. This combined approach reduces the need for future procedures and is probably more cost effective.

Semirigid ureteroscopy in management of large proximal ureteral calculi: is there still a role in developing countries?

OBJECTIVES

To evaluate the outcome and complications of the use of semirigid ureteroscopy (URS) together with intracorporeal pneumatic lithotripsy in the management of upper ureteral calculi >10 mm in diameter.

METHODS

A total of 75 patients (41 women and 34 men), with a mean age of 48 years (range 25-60), underwent primary URS for solitary radiopaque proximal ureteral calculi 10-20 mm in diameter (average 13.1). Dilation of the intramural ureter was done in 60 cases (80% of patients), and intracorporeal lithotripsy was required in 56 (74.6%). Ureteral catheters were left for drainage in 60% of patients, 26.7% were left unstented, and only 13.3% required an indwelling stent.

RESULTS

Of the 75 stones, 60 (80%) were successfully cleared after a single endoscopic procedure. Our initial stone-free rate was 90.6% at 2 weeks after the primary endoscopic procedure and had reached 98.6% at 3 months. Antegrade URS for migrating stones was done successfully in 6 cases in a tubeless fashion, and open ureterolithotomy was required in 1 case. No major complications were encountered. The minor complications included only mild extravasation and self-limited postoperative fever and hematuria. The risk factors for URS failure included male gender, the severity of the hydronephrosis, the severity of impaction, and the occurrence of extravasation.

CONCLUSIONS

The results of our study have shown that semirigid URS is a safe and successful alternative to open ureterolithotomy in the management of large proximal ureteral calculi in the absence of flexible instruments.

The management of renal caliceal calculi with a newly designed ureteroscope: a rigid ureteroscope with a deflectable tip

PURPOSE

To evaluate the indications for, and the effects of, the management of renal caliceal calculi with deflectable tip rigid ureteroscopy.

PATIENTS AND METHODS

We designed a new deflectable tip rigid ureteroscope, and 175 patients with renal caliceal calculi received deflectable tip rigid ureteroscopic lithotripsy with a holmium laser.

RESULTS

From December 2003 to December 2007, the procedure was successfully performed in all patients with a mean operative time of 28 minutes (range 19-45 min). The mean size of renal caliceal stones was 1.3 cm (range 0.8-2.4 cm). Seventeen patients had concurrent proximal ureteral calculi. The mean lithotripsy time was 11 minutes (range 5-22 min), and the mean discharge time was 3 days after operation. The overall stone-free rate at the 1-month follow-up was 83%.

CONCLUSION

Ureteroscopic lithotripsy with the novel deflectable tip rigid ureteroscope is a safe procedure and combines the advantages of rigid and flexible ureteroscopy, especially for renal caliceal calculi of relatively small size.

A prospective randomized study comparing shock wave lithotripsy and semirigid ureteroscopy for the management of proximal ureteral calculi

OBJECTIVES

To conduct a prospective randomized study comparing both techniques for the management of solitary radio-opaque upper ureteral stones < 2 cm in diameter. The ideal treatment for upper ureteral stones > 1 cm size remains to be determined with shock wave lithotripsy (SWL) and ureteroscopy (URS) being acceptable options.

METHODS

A total of 200 patients were included in the study. They were randomized into 2 equal groups. Group A underwent in situ SWL as a primary therapy. Group B underwent URS, using semirigid URS with intracorporeal lithotripsy. Efficiency quotient (EQ), cost analysis, and predictors of failure were estimated for both techniques.

RESULTS

For stones of size > or = 1 cm, the initial stone-free rate for URS and SWL was 88% and 60%, respectively. The estimated EQ was 0.79 and 0.43 for both techniques respectively. For stones < 1 cm, the initial stone-free rate for URS and SWL was 100% and 80%, respectively. The estimated EQ was 0.88 and 0.70 for both techniques, respectively. The mean cumulative costs were significantly more in SWL group (P <.05). Predictors of URS failure included; male gender, failure to pass guidewire beyond the stone, and extravasation. Predictors of SWL failure included large stone size > 1 cm, calcium oxalate monohydrate stone, and higher degrees of hydronephrosis.

CONCLUSIONS

URS with intracorporeal lithotripsy is an acceptable treatment modality for all proximal ureteral calculi, particularly stones > 1 cm. SWL should remain the first-line therapy for proximal ureteral calculi < or = 1 cm because of the less invasive nature and lower anesthesia (i.v. sedation).

Effect of ureteral access sheath on stone-free rates in patients undergoing ureteroscopic management of renal calculi

OBJECTIVES

To evaluate the effect of ureteral access sheaths (UASs) on stone-free rates (SFRs) during ureteroscopic treatment of renal calculi. Several advantages of UASs during flexible ureteroscopy have been documented. However, no study has evaluated their impact on SFRs.

METHODS

We retrospectively reviewed all ureteroscopic cases for the management of renal stones performed at our Stone Center. Data were stratified according to the use or lack of use of the UAS. The groups were stratified by stone location within the kidney. Stone-free status was determined at 2 months postoperatively by either intravenous urography with tomograms or noncontrast renal computed tomography in patients with contrast allergies.

RESULTS

A total of 256 ureteroscopic procedures for the removal of renal calculi were performed between 1997 and 2003 (173 with UAS and 83 without). The groups were similar in age, sex, and stone burden. Stents were placed in nearly 80% of patients. The lower renal pole represented the most common presenting location. Stone displacement with a ureteroscopic basket for efficient fragmentation was necessary in 34%. The overall SFR in the UAS group and non-UAS group was 79% and 67%, respectively (P = 0.042). The SFRs were improved for calculi in all portions of the kidney.

CONCLUSIONS

In addition to facilitating ureteroscopic access, reducing costs, and lowering intrarenal pressures, the results of the current study suggest that UASs improve SFRs during the management of renal calculi. It is now our current practice to use the UAS routinely during ureteroscopic treatment of renal and upper ureteral calculi.