Simultaneous saline irrigation during retrograde rigid ureteroscopic lasertripsy for the prevention of proximal calculus migration

Impact of forced diuresis on retropulsion of disintegrated ureteral calculi during semi-rigid ureteroscopy: a double-blind randomized-controlled study

The objective of this study is to assess the safety and efficacy of forced diuresis as an antiretropulsion strategy during the pneumatic disintegration of solitary lower ureteric stones with semi-rigid ureteroscopy (URS). A prospective randomized double-blind study was carried out from March 2019 to June 2021 for patients presented with unilateral solitary radiopaque lower ureteric stones ≤ 20 mm. Patients were randomized for URS into two groups, according to the use of forced diuresis using furosemide 1 mg/kg (GII) or not (GI). Perioperative parameters were compared between both groups, including retropulsion rate, stone-free rate (SFR), and need for auxiliary procedures and complications. A total of 148 patients were included; 72 (48.6%) in GI and 76 in the GII (51.4%), with respective stone size of 11.8 ± 2.6 vs.12.1 ± 2.4 mm. Both groups were comparable in demographic and baseline data, with a mean age of 47 ± 16 and 50 ± 14 years for GI and GII, respectively. GII had a significantly shorter disintegration time (10.5 ± 1.3 vs. 4.2 ± 2.1 min, p < 0.001), shorter operative time (33.1 ± 10.1 vs. 40.8 ± 9.1 min, p < 0.001), lower stone fragments migration rate during disintegration (6.5% vs. 18.1%, p = 0.04), lower retropulsion rate (1.3% vs. 11%, p = 0.02), higher SFR (96.1% vs. 86.1%, p = 0.04), and lower auxiliary procedures (3.9% vs. 13.8%, p = 0.03). Intraoperative and 6-h postoperative changes in heart rate and mean systolic blood pressure were comparable between both groups. Ephedrine injection (6–18 mg) was needed in significantly more GII patients (39.5% vs. 20.8%, p ≤ 0.01). It seems that forced diuresis during pneumatic lithotripsy of the lower ureteric stones is a safe and effective antiretropulsion technique. This would expand the alternative options to the antiretropulsion strategy, especially in centers where the laser and flexible ureteroscopes are not available.

The Role of Antegrade Irrigation via Percutaneous Nephrostomy on Surgical Outcomes in Semirigid Ureteroscopy among Patients with Upper Ureteral Stones

Objective

We aimed to investigate the role of antegrade irrigation via percutaneous nephrostomy on surgical outcomes in retrograde ureteroscopy in patients with upper ureter stones.

Materials and Methods

In this retrospective study, we analyzed 134 patients who underwent retrograde semirigid ureteroscopy for upper ureter stones between August 2012 and December 2017. Patients were divided into two groups: retrograde irrigation group (conventional URS) and antegrade irrigation group (using percutaneous nephrostomy). Operation time, postoperative hospital stay, complications, and stone-free rate were measured for each patient after ureteroscopy.

Results

The mean age in the retrograde irrigation and antegrade irrigation groups was 53.3 and 60.7 years, respectively (p=0.007). The operation time was 60.8 min vs. 43.0 min (p=0.002), and stone-free rate was 82.0 % vs. 95.5 % (p=0.033). Stone size, laterality, the proportion of male patients, and urinary tract infection prevalence were comparable between the groups. In the subgroup analysis of stone size >10 mm, the antegrade irrigation group had a shorter operation time and a higher stone-free rate. For stone size of 5-10 mm, operation time in the antegrade irrigation group was shorter and the stone-free rate between the two groups was comparable.

Conclusion

Antegrade irrigation via percutaneous nephrostomy during ureteroscopy has a higher stone-free rate with a shorter operation time without an increased urinary tract infection risk. Therefore, if percutaneous nephrostomy is necessary before ureteroscopy, antegrade irrigation of external fluid via percutaneous nephrostomy is strongly recommended.

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.