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

Retrograde intrarenal surgery for asymptomatic incidental renal stones: a retrospective, real-world data analysis

OBJECTIVE

To determine surgical outcomes and stone-free rates (SFRs) when offering upfront retrograde intrarenal surgery (RIRS) to patients with asymptomatic incidental renal stones (AIRS), as active surveillance, shockwave lithotripsy or upfront intervention in patients with AIRS is still a debate among urologists.

PATIENTS AND METHODS

This retrospective FLEXible Ureteroscopy Outcomes Registry (FLEXOR), supported by the Team of Worldwide Endourological Researchers (TOWER), examines adult patients who underwent RIRS. We analysed a subset of asymptomatic patients with renal stones on imaging who were treated with RIRS. Data includes patient characteristics, stone specifications, anaesthesia type, perioperative details, complications, and SFR. A multivariable logistic regression analysis was performed to assess factors associated with the SFR.

RESULTS

Among 679 patients with AIRS, 640 met the inclusion criteria. The median age was 55 years, with 33.4% being female. In all, 22.1% had positive urine cultures. The median stone diameter was 12 mm, commonly in lower and interpolar locations. RIRS was preferentially performed under general anaesthesia using a reusable scope in 443 cases. Prophylactic antibiotics were administered to 314 patients. The median operation time was 58 min and the median laser time was 24 min. The SFR was 68.8%. The use of holmium laser (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.06-0.63; P < 0.01) and multiple stones (OR 0.38, 95% CI 0.19-0.76; P < 0.01) were factors associated with lower odds of being stone free. Overall complications were minimal, with sepsis in 1.6% of patients. Re-interventions were performed in 76 cases (11.8%), with RIRS being the most common in 67 cases (10.6%).

CONCLUSION

Our multicentre real-world study is the first of its kind that highlights the pros and cons of offering RIRS to patients with AIRS and demonstrates a favourable SFR with acceptable complications. Pre-emptively discussing potential re-intervention helps patients make informed decisions, particularly in cases involving large and multiple stones.

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.).

Combination of transurethral resection of the prostate and flexible and rigid ureteroscopy for benign prostatic hyperplasia and ureteral calculus

Background

Combination of transurethral resection of the prostate (TURP) and flexible and rigid ureteroscopy (URS/RIRS) is a successful approach for patients with benign prostatic hyperplasia (BPH) and ureteral calculus (UC), and the sequence is URS/RIRS followed by TURP. This research aims to compare TURP followed by URS/RIRS with URS/RIRS followed by TURP in terms of clinical efficiency and safety.

Methods

From June 2009 to June 2021, 173 patients with BPH and upper urinary tract stones were recruited through the Harrison International Peace Hospital and were divided into intervention (TURP followed by URS/RIRS) and control groups (URS/RIRS followed by TURP). We collected demographic data, primary outcomes including urinary function, and secondary outcomes including surgical parameters and complications. SPSS 21.0 was used to analyze data.

Results

When comparing the surgical parameters, the intervention group showed better results than the control group regarding surgery time and length of hospitalization. When comparing urinary function and complications, there were no differences between the intervention and control groups.

Conclusions

Although the intervention of TURP followed by URS/RIRS had similar clinical effects compared with URS/RIRS followed by TURP in the control group; the intervention saves surgery time, and decreases the length of stay and medical costs. It may therefore be a good choice for patients with BPH and UC.

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.

The "old" 15 mm renal stone size limit for RIRS remains a clinically significant threshold size

PURPOSE

To investigate the performance of retrograde intrarenal surgery (RIRS) for the 1-2 cm renal stone size range in comparison to smaller stones.

MATERIALS AND METHODS

From a data base of 3000 ureteroscopies between 2004 and 2014, 635 consecutive patients underwent RIRS for renal stones. Patients were divided to three groups according to their renal stone size (<10, 10-15, 15-20 mm). Preoperative, operative, stone free rate (SFR) and follow-up data were analyzed and compared.

RESULTS

The SFR for the three groups was 94.1, 90.1 and 85%, respectively. Patients with renal stone size above 15 mm had a statistically significantly lower SFR. The efficiency quotient calculated for stones larger and smaller than 15 mm was 83.9 vs. 91.8%, respectively (p < 0.01). The mean operative time and hospital stay were longer for patients with renal stones larger than 15 mm (73.6 ± 29.9 vs. 53 ± 19.4 min, p < 0.01 and 2.2 ± 2 vs. 1.8 ± 1.8 days, p = 0.031, respectively). Moreover, the complication rate was almost two times higher (10 vs 5.4%, p = 0.08). Concomitant ureteral stones and older age were independent predictors of failure in the large stone group.

CONCLUSIONS

While the overall SFR following RIRS for renal stones up to 2 cm is generally high, the SFR for 15-20 mm stones is significantly lower, with a longer operating time and hospital stay, and a higher complication rate.

Megacystis microcolon intestinal hypoperistalsis syndrome: Case series and updated review of the literature with an emphasis on urologic management

INTRODUCTION

Megacystis microcolon intestinal hypoperistalsis (MMIHS) is a rare disorder characterized by distended nonobstructed bladder, microcolon, and decreased intestinal peristalsis. MMIHS has a particularly poor prognosis; however, when appropriately managed, survival can be prolonged.

STUDY DESIGN

A systematic review (1996-2016) was performed with the key words "megacystis microcolon intestinal hypoperistalsis syndrome." In addition, a case series of four patients is presented as well as algorithms for the diagnosis and treatment of MMIHS.

RESULTS

135 patients with MMIHS were identified in the literature. 73% (88/121) of the patients were female, 65% underwent diagnostic biopsy (64/99), and 63% (66/106) were identified with prenatal imaging. The majority of patients were treated with TPN as well as gastrostomy or ileostomy and CIC, however 15% (18/116) received multivisceral or intestinal transplant, and 30% (22/73) had a vesicostomy. The survival rate was 57% (68/121).

CONCLUSION

Appropriate management of MMIHS patients is crucial. An enlarged, acontractile bladder in a child with bowel motility problems should be considered diagnostic. Bladder distension can be managed with CIC or vesicostomy in addition to prophylactic antibiotics if frequent urinary tract infections are present. These patients often require gastrostomy or ileostomy as well as total parenteral nutrition. This management has led to significant improvement in survival rates.

Is semirigid ureteroscopy sufficient in the treatment of proximal ureteral stones? When is combined therapy with flexible ureteroscopy needed?

The goals of this study were to examine cases of proximal ureteral stones in which semirigid or flexible ureteroscopes alone were insufficient for endoscopic treatment, requiring the combination of both. A total of 137 patients were retrospectively evaluated. Holmium laser was used as the energy source for stone fragmentation. Each operation was begun with a 6/7.5 Fr semirigid ureteroscope (URS), and continued with a 7.5 Fr flexible URS in those procedures that failed to reach the stone or push-up. Double J stents were inserted into those patients in whom the flexible URS failed. Shock wave lithotripsy (SWL) or a repeat ureteroscopy (after 2-4 weeks) was planned in those patients who were considered to be treated unsuccessfully. The demographic features of the patients, stone sizes, treatment outcomes, need for additional treatment, complications, and the results of the postoperative 1-month early follow-up were evaluated. The mean age of the patients (77 males and 60 females) was 38 ± 6.7 years old, the mean stone size was 12.3 ± 3.7 mm, and the number of patients with persistent hydronephrosis was 86 (62.8 %). A stone-free diagnosis was achieved in a total of 124 patients (90.5 %), using a semirigid URS in 80 patients and a flexible URS in 44 patients. Treatment using a flexible URS was administered in 38 patients (27.7 %) due to push-up, and in 6 patients (4.3 %) because of the failure to advance the semirigid URS into the ureter. The treatment failed in 13 patients (9.4 %) despite the use of both methods. Treatment using low-caliber semirigid ureteroscopy and a holmium laser is possible, regardless of the stone size, in female patients without hydronephrosis. However, the need for combined treatment with flexible ureteroscopy is increased in male patients with hydronephrosis.

Urolithiasis in pregnancy: a cost-effectiveness analysis of ureteroscopic management vs ureteral stenting

OBJECTIVE

The purpose of this study was to determine the cost-effectiveness of serial stenting vs ureteroscopy for treatment of urolithiasis during pregnancy as a function of gestational age (GA) at diagnosis.

STUDY DESIGN

We built decision analytic models for a hypothetical cohort of pregnant women who had received a diagnosis of symptomatic ureteral calculi and compared serial stenting to ureteroscopy. We assumed ureteral stent replacement every 4 weeks during pregnancy, intravenous sedation for stent placement, and spinal anesthetic for ureteroscopy. Outcomes were derived from the literature and included stent infection, migration, spontaneous kidney stone passage, ureteral injury, failed ureteroscopy, postoperative urinary tract infection, sepsis, and anesthetic complications. Four separate analyses were run based on the GA at diagnosis of urolithiasis. Using direct costs and quality-adjusted life years, we reported the incremental costs and effectiveness of each strategy based on GA at kidney stone diagnosis and calculated the net monetary benefit. We performed 1-way and Monte-Carlo sensitivity analyses to assess the strength of the model.

RESULTS

Ureteroscopy was less costly and more effective for urolithiasis, irrespective of GA at diagnosis. The incremental cost of ureteroscopy increased from -$74,469 to -$7631, and the incremental effectiveness decreased from 0.49 to 0.05 quality-adjusted life years for a kidney stone diagnosed at 12 and 36 weeks of gestation, respectively. The net monetary benefit of ureteroscopy progressively decreased for kidney stones that were diagnosed later in pregnancy. The model was robust to all variables.

CONCLUSION

Ureteroscopy is less costly and more effective relative to serial stenting for urolithiasis, regardless of the GA at diagnosis. Ureteroscopy is most beneficial for women who received the diagnosis early during pregnancy.

Current status of flexible ureteroscopy in urology

Retrograde intrarenal surgery (RIRS) is being performed for the surgical management of upper urinary tract pathology. With the development of surgical instruments with improved deflection mechanisms, visuality, and durability, the role of RIRS has expanded to the treatment of urinary calculi located in the upper urinary tract, which compensates for the shortcomings of shock wave lithotripsy and percutaneous nephrolithotomy. RIRS can be considered a conservative treatment of upper urinary tract urothelial cancer (UTUC) or for postoperative surveillance after radical treatment of UTUC under an intensive surveillance program. RIRS has a steep learning curve and various surgical techniques can be used. The choice of instruments during RIRS should be based on increased surgical efficiency, decreased complications, and improved cost-benefit ratio.

Predicting an effective ureteral access sheath insertion: a bicenter prospective study

INTRODUCTION

The use of a ureteral access sheath (UAS) may provide significant advantages, particularly, in the treatment of a large renal stone burden. However, in some patients, the passage of a UAS up the ureter is impossible. We prospectively evaluated the ability to insert a 14F UAS and analyzed the possible predictors for an effective insertion.

PATIENTS AND METHODS

In a bicenter prospective study, 248 consecutive patients undergoing ureteroscopy and retrograde intrarenal surgery (RIRS) were recruited. In each case, we attempted initially to pass a 14F Flexor-Cook UAS. If passage was difficult, gradual dilation using semirigid ureteral dilators (Cook Medical) was performed. Patients were categorized into three groups: effective passage, with and without dilation, and failure to pass the UAS. Age, gender, body-mass index (BMI), an indwelling Double-J stent, and a history of previous ureteroscopy or Double-J stent were all analyzed, as possible predictors for an effective UAS insertion.

RESULTS

In 22% of the patients, we could not pass a 14F UAS. Of the preoperative parameters that were examined, we found three independent predictors for an effective 14F UAS insertion: age (odds ratio: 1.5 and 95% CI [1.3, 1.9]), previous same-side procedures (odds ratio: 9.7 and 95% CI [8.3, 14.5]), and an indwelling Double-J stent (odds ratio: 21.73 and 95% CI [20, 30]). The gender, BMI, and side of surgery did not predict the success rate.

CONCLUSIONS

Insertion of a 14F UAS before RIRS may fail in approximately one-fifth of the patients. An indwelling Double-J stent, a history of previous ureteroscopy or Double-J stent, and older age are all significant predictors for an effective 14F UAS insertion.

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.

Simultaneous retrograde intrarenal surgery for ipsilateral asymptomatic renal stones in patients with ureteroscopic symptomatic ureteral stone removal

Background

Ipsilateral asymptomatic renal stone associated with symptomatic ureteral stone is not a rare event, and the recommended treatment policy was not declared clearly. This study was conducted to compare the outcomes of simultaneous retrograde intrarenal surgery (RIRS) and ureteroscopy to ureteroscopy alone for this clinical event.

Methods

415 patients with symptomatic ureteral stone and ipsilateral asymptomatic renal stones were reviewed to obtain two match groups, who were treating with simultaneous modality (group A, N = 72), or ureteroscopy alone (group B, N = 72). Matching criteria were ureteral and renal stone side, duration and location, the presence of pre-stented. Perioperative and postoperative characteristics were compared between the two groups.

Results

Mean stone burdens were similar between group A and B. Mean operative duration for group A and B were 72.4 ± 21.3 and 36.4 ± 10.2 min, respectively (P < 0.001). Mean hospital duration was 6.4 ± 2.9 and 5.3 ± 2.1 days in group A and B, respectively (P = 0.521). Ureteral SFR was 100% in each group. Renal SFR for RIRS was 86.1%. Complication rates in group A were higher (22.2% vs 13.9%), but the differences were not statistically significant (P = 0.358). In group A, complications were significantly less in pre-stented patients (3/25 vs 5/11, P = 0.04). Auxiliary treatment rate was significant higher in group B (69.4% vs 5.6%, P < 0.001) during follow-up (mean >18 months).

Conclusions

Simultaneous RIRS for ipsilateral asymptomatic renal stones in patients with ureteroscopic symptomatic ureteral stone removal can be performed safely and effectively. It promises a high SFR with lower auxiliary treatment rate, and does not lengthen hospital duration and increase complications.