Abstract
ABSTRACTObjectives: To compare stone dusting and spontaneous passage vs fragmentation and active fragment retrieval during flexible ureteroscopy (fURS) for renal calculi.Patients and methods: The study included patients who underwent fURS and holmium laser lithotripsy for renal calculi from January 2015 to March 2017. Dusting was done using low energy and high frequency (0.3–0.5 J and 15–20 Hz, respectively), and fragmentation was done with higher energy and lower frequency (1–1.2 J and 6–10 Hz, respectively) and then stone fragments were extracted using a basket. The stone-free rate (SFR) was evaluated after 2 months with non-contrast computed tomography. Operative time, complication rate, SFR, and the need for secondary procedures were compared.Results: The study included 107 consecutive patients, with a mean (SD) age of 49 (13) years. Dusting was performed in 51 patients and fragmentation in 56. The patients’ demographics, laboratory tests, preoperative stents, stone and renal characteristics were comparable for both groups. Operative time was significantly shorter for dusting than fragmentation (76 vs 91 min, P = 0.009). Complication rates were comparable between the groups (7.8% for dusting and 8.9% for fragmentation, P = 0.840). The mean hospital stay was comparable for both groups (P = 0.686). The SFR was significantly better in fragmentation group (78.6%) compared with the dusting group (58.6%, P = 0.035). The need for a secondary procedure was 33.3% in the dusting group and 23.3% in fragmentation group (P = 0.244).Conclusions: During fURS for renal stones, the dusting technique had a significantly shorter operation time, whilst the fragmentation technique led to a significantly better SFR. Both techniques have comparable safety, hospital stay, and requirement for secondary procedures.Abbreviations: fURS: flexible ureteroscopy/ureteroscope; ICU: intensive care unit; KUB: plain abdominal radiograph of the kidney, ureter and bladder; NCCT: non-contrast CT; SFR: stone-free rate; SWL: shockwave lithotripsy; UAS: ureteric access sheath
Highlights
Flexible ureteroscopy is currently the preferred treatment option for most uncomplicated renal calculi [1]. This has resulted from the marked improvement in fURS designs, laser lithotripsy machines and techniques, as well as working instruments [2]
After completing stone dusting or fragmentation, the ureter was inspected during withdrawal of the fURS for any injury caused by the ureteric access sheath (UAS)
Of 114 patients who were scheduled for fURS for renal stones, three patients were excluded due to failure to reach the stones and they underwent minimally invasive percutaneous nephrolithotomy
Summary
Flexible ureteroscopy (fURS) is currently the preferred treatment option for most uncomplicated renal calculi [1]. This has resulted from the marked improvement in fURS designs, laser lithotripsy machines and techniques, as well as working instruments [2]. The holmium:yttrium-aluminium-garnet (YAG) laser has become the preferred lithotripter device because of its high efficacy and the availability of small-diameter (200 μm) flexible laser fibres, which can pass through the fURS and reach any site in the calyceal system [2]. Low energy (0.2–0.5 J), high frequency (15–40 Hz) lithotripsy results in tiny fragment sizes that can pass spontaneously and this technique has been termed ‘dusting’. Higher energy levels (1–1.2 J) with lower frequencies (6–10 Hz) results in fragments that require active retrieval with baskets and this technique has been termed ‘fragmentation’ [7,8]
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