Bilateral single-session retrograde intra-renal surgery: A safe option for renal stones up to 1.5 cm

Play it safe: renal function after bilateral flexible ureteroscopy for kidney stones

PURPOSE

We searched for perioperative renal function deterioration risk factors in patients that underwent bilateral flexible ureteroscopy (fURS) for kidney stones.

METHODS

From August 2016 to February 2020, symptomatic patients > 18 years old with bilateral kidney stones up to 20 mm in each side were prospectively studied. Serum creatinine samples were collected on admission to surgery, immediate postoperative (IPO), on POD 3, 10, and 30. Estimated glomerular filtration rate (eGFR) was calculated using Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI) without a race coefficient.

RESULTS

Thirty patients underwent bilateral fURS. Comparing to preoperative eGFR, median IPO and POD3 eGFR (p < 0.001) were significantly lower, and POD10 (p = 0.092) and POD30 (p = 0.648) were similar to preoperative eGFR. During follow-up, 22/30 (73.3%), 14/30 (46.7%), and 7/30 (23.3%) of the patients presented a decrease > 10% eGFR, > 20% eGFR, and > 30% eGFR, respectively. Multivariate analysis demonstrated that lower preoperative eGFR is a risk factor for eGFR < 60 mL/min/1.73 m2, p = 0.019 [1.021-1.263; 1.136]; ASA > 1 is a risk factor for decrease of eGFR > 10%, p = 0.028 [1.25-51.13; 8.00]; longer operative time is a risk factor for decrease of eGFR > 20%, p = 0.042 [1.00-1.05; 1.028]; and operative time ≥ 120 min is a risk factor for decrease of eGFR > 30%, p = 0.026 [0.016-0.773; 0.113].

CONCLUSIONS

Renal function suffers a reversible decrease after bilateral fURS. Our study suggests that adequate selection of patients and maintaining operative time < 120 min are relevant factors in preventing acute renal function deterioration following bilateral fURS.

Bilateral same session flexible ureterorenoscopy for endoscopic management of bilateral renal calculi is noninferior to unilateral flexible ureterorenoscopy for management of multiple unilateral renal calculi: outcomes of a prospective comparative study

PURPOSE

The aim of the study was to prospectively evaluate safety and efficacy of bilateral same session ureterorenoscopy (BSS-FURS) for management of bilateral renal calculi.

METHODS

A prospective comparative study was designed to compare the results of BSS-FURS with unilateral flexible ureterorenoscopy (U-FURS) for management of renal calculi between June 2003 and May 2016. A sample size of 55 patients in each arm was calculated considering a 20% increase in the incidence of complications with BSS-FURS over 15% complication rate in U-FURS (alpha = 0.05; Beta = 0.90). Patient demographics, stone burden, total operative time, postoperative creatinine level, duration of hospital stay, perioperative complications and stone free rate (SFR) were compared in both the groups. The literature pertaining to BSS-FURS was reviewed.

RESULTS

Although the study group patients had higher overall stone burden (18.60 ± 7.70 mm vs. 13.32 ± 6.43 mm) and significantly longer operative time (48.30 ± 16.71 min vs. 32.95 ± 13.05 min; p < 0.05) as compared to the control group, the length of hospital stay, SFR (67.85% vs. 78.5%; p = 0.436) and perioperative complications were comparable in both the groups. Most patients who developed postoperative fever from both groups had struvite stones.

CONCLUSION

BSS-FURS is a safe and efficient procedure for the management of bilateral renal calculi in the hands of an experienced endourologist. It has comparable SFR and morbidity compared to U-FURS. Caution should be exercised in patients with struvite stones, as they are more likely to develop postoperative fever.

Prediction of stone-free status after single-session retrograde intrarenal surgery for renal stones

OBJECTIVE

To determine the possible factors effecting stone-free status (SFS) after single-session retrograde intrarenal surgery (RIRS) for renal stones.

MATERIAL AND METHODS

We retrospectively analyzed the charts of 100 consecutive patients who underwent RIRS. Unilateral procedures performed for single renal stones were included in the study. The studied parameters included patient demographics, stone characteristics (size, volume, location and attenuation according to Hounsfield unit [HU]), operation time, presence of preoperative double-J stent (DJS), use of ureteral access sheath (UAS) and SFS.

RESULTS

The study population consisted of 100 patients where 43 of them were stone free and remaining 57 had residual stones. The mean age of the patients was 47.2±13.4 years. The mean stone size (largest dimension), stone attenuation and stone volume were 14.8±5.8 mm, 1010±416 HU and 937±929 mm³, respectively. The mean operative time was 60.8±24.2 minutes. Mean stone size, volume and HU were higher in the RS group compared to SF group but without any statistically significant difference, 15.2±6.1 vs. 14.2±5.3 mm, 1056±1037 mm³ vs. 780±745 mm³ and 1061±374 HU vs. 942±462 HU, respectively (p=0.490, p=0.135 and p=0.226). In multivariate regression analysis stone location and UAS use were found to be the significant predictors of SFS. Patients with lower pole stones are 2.25 times likely to have residual stones after RIRS compared to patient's having stones at other localizations (p<0.001).

CONCLUSION

Stone volume could be a more reliable parameter than stone size in predicting RIRS success. Lower pole stone location and UAS use could be considered the most significant predictors of SFS after single session RIRS for single renal stones.

Bilateral Simultaneous Ureteroscopic (BS-URS) Approach in the Management of Bilateral Urolithiasis Is a Safe and Effective Strategy in the Contemporary Era-Evidence from a Systematic Review

PURPOSE OF REVIEW

Ureteroscopic treatment of urolithiasis has become safer and more effective in the modern era. With a rise in the incidence of bilateral urolithiasis, management dilemma of staged single-side ureteroscopy versus bilateral simultaneous ureteroscopy (BS-URS) is often debatable. This review evaluates the current evidence base for bilateral simultaneous ureteroscopic approach in the modern era.

RECENT FINDINGS

A systematic review was conducted from 1990 to June 2016 including all English language articles reporting on outcomes of BS-URS for urolithiasis. Data was split into two periods: period 1: 2003-2012 and period 2: 2013-2016, and analysed using SPSS version 21. A total of 11 studies (491 patients) were identified from a literature search of 148 studies with mean age of 45 years and a male: female ratio of 2:1 and a mean operative time of 69 min (SD = ±15). The initial and final stone-free rate (SFR) was 87 and 93%, respectively. Post-operative stents were placed in 89% of patients with a mean hospital stay of 1.6 days (SD = ±0.5). Overall, there was a significant negative association between case volume (procedures per month) and complication rate (p = 0.045). Mean hospital stay was significantly longer in period 1 (1.9 days, SD = ±0.5) than period 2 (1.3 days, SD = ±0.3) and complications were also significantly higher in period 1 (47%) compared to period 2 (12%) (p < 0.001). There were six studies examining holmium laser (HL) lithotripsy and three examining pneumatic lithotripsy (PL). There were significantly more complications after PL than HL; however, their SFR was similar. Our review shows that the complication rates and hospital stay are significantly reduced in the contemporary data suggesting an improving trend in outcomes following BS-URS. Simultaneous bilateral ureteroscopic treatment of urolithiasis is safe and effective in the modern era. Safety is increased in centers with increased number of procedures performed and with laser lithotripsy.