Role of pelvicalyceal anatomy in the outcomes of retrograde intrarenal surgery (RIRS) for lower pole stones: outcomes with a systematic review of literature

Sulaiman Sadaf Karim,Bhaskar K Somani,Robert Geraghty,Luke Hanna

doi:10.1007/s00240-019-01150-0

Sulaiman Sadaf Karim, Bhaskar K Somani + Show 2 more

Open Access

https://doi.org/10.1007/s00240-019-01150-0

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Abstract

Controversies exist on the influence of lower pole anatomy (infundibular pelvic angle, IPA; infundibular length, IL; and infundibular width, IW) for success and outcomes related to the treatment of stones in the lower pole. We wanted to look at the role of lower pole anatomy to study clinical outcomes in patients treated for isolated lower pole stones (LPS) using retrograde intra renal surgery (RIRS), and also perform a review to look at the published literature on the influence of pelvicalyceal anatomy on success with RIRS. Data were prospectively collected (June 2013–June 2016) for all patients who underwent RIRS for LPS, and the imaging was then retrospectively reviewed to calculate the IPA, IL and IW using the Elbahnasy method. A systematic review was also conducted for all English language articles between January 2000 and April 2018, reporting on the impact of pelvicaliceal anatomy on RIRS. A total of 108 patients with LPS were included with a male to female ratio of 2:3 and a mean age of 54.7 years. The mean lower pole stone size was 9.3 mm (range 3–29 mm) and 102/108 (94.4%) patients were stone free (SF) at the end of their procedure. While steep IPA (< 30°), operative time duration and larger stone size were significant predictors of failure, the placement of ureteric access sheath, IW and IL did not influence treatment outcomes. Six studies (460 patients) met the inclusion criteria for our review. The IPA, IW, IL for failure ranged from 26° to 38°, 5.5–7 mm and 24–34 mm, respectively. The SFR ranged from 78 to 88% with a metaanalysis showing IPA as the most important predictor of treatment outcomes for LPS. Infundibular pelvic angle seems to be the most important predictor for the treatment of LPS using RIRS. Pelvicalyceal anatomy in conjunction with stone size and hardness seem to dictate the success, and decisions on the type of surgical interventions should reflect this.

Highlights

With an increase in the incidence of stone disease over the last 2 decades, there has been a corresponding rise in the surgical procedures undertaken for it [1,2,3]
A semi rigid ureteroscopy was performed over a working guidewire up to the pelvi-ureteric junction (PUJ) or as far proximally as safely achievable, which helped in the calibration of the ureter to judge whether a ureteral access sheath (UAS) could be inserted
The placement of a ureteric access sheath had no significant impact on stone free rate (SFR) (p = 0.53)

Summary

Introduction

With an increase in the incidence of stone disease over the last 2 decades, there has been a corresponding rise in the surgical procedures undertaken for it [1,2,3]. Majority of stones in the kidney are located in the lower pole calyx [4]. Treatment of stones in the lower calyx includes shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) [4]. Stone treatment in the lower pole is less successful compared to treatment elsewhere in the kidney [5]. The risk of stone formation seems to be associated with a large calyceal volume and narrow infundibulum [6]. The impact of renal anatomy while treating lower pole renal stones (LPS) with SWL is well established, this is less well known and poorly evidenced with RIRS

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