Clinically Insignificant Residual Fragments Research Articles

Comparative analysis of scoring systems for patients undergoing retrograde intrarenal surgery with isolated lower calyx stones.

It is critical to provide patients with accurate information on potential surgical outcomes during the preoperative phase. Several scoring systems have been developed for this specific purpose. This study aimed to examine the predicted efficacy of scoring systems in patients with isolated lower calyx stones who underwent retrograde intrarenal surgery (RIRS). We performed a retrospective analysis of 85 patients who underwent RIRS for lower calyx stones between 2016 and 2023. The study computed each participant's Resorlu-Unsal Stone score (RUSS), R.I.R.S. scoring system score, Modified Seoul National University Renal Stone Complexity (S-ReSC) score, S.T.O.N.E. score, Ito's nomogram, and T.O.HO score. Residual stones less than 4mm were classified as clinically insignificant residual fragments (CIRFs) and regarded as successful. Following that, we used receiver-operating characteristic (ROC) curves to compare various scoring systems' success predictions. The median scores for RUSS, R.I.R.S. scoring system, Modified S-ReSC, S.T.O.N.E., Ito's nomogram, and T.O.HO score were 1 (1), 7 (2), 2 (0), 11 (1), 18 (4), and 7 (1), respectively. When CIRF cases were included, the stone-free rate increased to 80%. Only Ito's nomogram from scoring systems has a statistically significant cut-off value for success in ROC analysis (p = 0.021). In multivariate analysis, stone volume and preoperative hydronephrosis were associated with success (p = 0.004 and p = 0.035, respectively). In the multivariate analysis, none of the scoring systems were significantly associated with success. Hence, a new scoring system must be developed exclusively for patients with isolated lower pole stones undergoing RIRS.

What is the definition of stone dust and how does it compare with clinically insignificant residual fragments? A comprehensive review.

During endoscopic stone surgery, Holmium:YAG(Ho:YAG) and Thulium Fiber Laser(TFL) technologies allow to pulverize urinary stones into fine particles, ie DUST. Yet, currently there is no consensus on the exact definition of DUST. This review aimed to define stone DUST and Clinically Insignificant Residual Fragments(CIRF). Embase, MEDLINE(PubMed) and Cochrane databases were searched for both in vitro and in vivo articles relating to DUST and CIRF definitions, in November 2023, using keyword combinations: "dust", "stones", "urinary calculi", "urolithiasis", "residual fragments", "dusting", "fragments", "lasers" and "clinical insignificant residual fragments". DUST relates to the fine pulverization of urinary stones, defined in vitro as particles spontaneously floating with a sedimentation duration ≥ 2sec and suited for aspiration through a 3.6Fr-working channel(WC) of a flexible ureteroscope(FURS). Generally, an upper size limit of 250µm seems to agree with the definition of DUST. Ho:YAG with and without "Moses Technology", TFL and the recent pulsed-Thulium:YAG (pTm:YAG) can produce DUST, but no perioperative technology can currently measure DUST size. The TFL and pTm:YAG achieve better dusting compared to Ho:YAG. CIRF relates to residual fragments(RF) that are not associated with imminent stone-related events: loin pain, acute renal colic, medical or interventional retreatment. CIRF size definition has decreased from older studies based on Shock Wave Lithotripsy(SWL)(≤ 4mm) to more recent studies based on FURS(≤ 2mm) and Percutaneous Nephrolithotomy(PCNL)(≤ 4mm). RF 2mm are associated with lower stone recurrence, regrowth and clinical events rates. While CIRF should be evaluated postoperatively using Non-Contrast Computed Tomography(NCCT), there is no consensus on the best diagnostic modality to assess the presence and quantity of DUST. DUST and CIRF refer to independent entities. DUST is defined in vitro by a stone particle size criteria of 250µm, translating clinically as particles able to be fully aspirated through a 3.6Fr-WC without blockage. CIRF relates to ≤ 2 RF on postoperative NCCT.

The fate of clinically insignificant residual fragments following retrograde intrarenal surgery and factors affecting spontaneous passage.

The remaining stone fragments after retrograde intrarenal surgery (RIRS) can lead to stone recurrence/regrowth, or stone-related events (SRE). We aimed to delineate the clinical circumstances that are decisive for spontaneous passage of clinical insignificant residual fragments (CIRF) (primary outcome) and define risk factors for stone recurrence/regrowth and their clinical manifestation (secondary outcome). A total of 115 patients who had CIRF following RIRS were included in this study. Demographic, clinical data, stone, and anatomic characteristics including infundibulopelvic angle (IPA), infundibular length (IL) and follow-up data of patients were analyzed. The mean follow-up time was 27.5 ± 6.9months. 31 (26.9%) patients passed the CIRF spontaneously. Patients were divided into two groups as spontaneous fragment passage group and fragment remaining group and compared with respect to demographic, clinical, stone-related, and anatomic characteristics. 61.2% of patients had lower pole CIRF in fragment remaining group and 83.3% of patients in spontaneous fragment passage group (p = 0.031). In addition, IPA was wider in spontaneous fragment passage group (60.7° vs 51.4°, p = 0.001). A subanalysis was performed for fragment remaining group. In 84 patients, 44 (52.4%) patients were stable for their CIRF at their follow-up and included in stable group. 40 (47.6%) patients experienced stone re-growth (27 patients) or SRE (13 patients) at their follow up. Patients in re-growth/SRE group were older (49.1 vs 39.4years, p = 0.047), had higher body mass index (28.2 vs 27kg/m2, p = 0.03) and larger CIRF (2.8 vs 2.1mm). CIRFs may be not expelled spontaneously and they may lead to additional morbidity and lithotripsy interventions.

Extracorporeal Shock Wave Lithotripsy (ESWL): An Evaluation of Success in Low, Medium and High Stone Density

Objective: To find the frequency of patients of renal calculi with different stone densities and to evaluate the success rate of ESWL treatment in selected groups of patients i.e. low, medium and high stone density. Methodology: In this descriptive case series, at Department of Urology, Services Hospital, Lahore was conducted and enrolled a 100 cases with single, radiopaque renal stone of 1-2 cm (10 to 20 mm), between 15-80 years of either gender whereas those with calculus in nonfunctioning kidney (GFR less than 15 ml/min), calculus in Pyonephrotic kidney, presence of JJ stent and having previous surgery for stone on same side or radiolucent stones were excluded from this study. All sessions of ESWL were performed following departmental protocol. 3 weeks after the ESWL session, the outcome was evaluated by plain X-ray KUB and USG KUB. In this analysis, ESWL success was defined as either total stone clearance or the presence of clinically insignificant residual fragments (CIRFs) (4 mm, peripheral, not producing renal colic, with no infection or extensive hematuria). Results: Stone density was in the range of 335-1900 HU with a mean density of 851.1 (±418) HU. Patients with medium density group (500-1000HU) were significantly greater than other two groups. MDG had frequency of 51% followed by LDG (25%) and HDG (24%). Overall, ESWL success rate was 82% in all the 100 patients of renal calculi. Success rate was greatest in LDG i.e. 100%. MDG had a success rate of 90% and only 45.8% of the patients in HDG had succees after ESWL treatment. Success rate decreased as the stone density increased. Conclusion: the stone density has a significant impact on success of ESWL. NCCT stone characteristics like mean density in HU and demographic characteristics are potential predictors for evaluation of success of ESWL. Keywords: Kidney stones, ESWL, Stone density

Totally X-ray-Free Ultrasound-Guided Mini-Percutaneous Nephrolithotomy in Galdakao-Modified Supine Valdivia Position: A Novel Combined Surgery.

We introduced a novel surgery that combines ultrasound guidance, miniaturization and Galdakao-modified supine Valdivia (GMSV) position in percutaneous nephrolithotomy (PCNL) and evaluated the safety and efficacy. This retrospective, single-center study retrospectively reviewed 150 patients who underwent ultrasound-guided mini-PCNL in the GMSV position from November 2019 to March 2022. All perioperative parameters were collected. Stone-free status was defined as no residual stones or clinically insignificant residual fragments (CIRF) <0.4 cm on postoperative day one. Among the 150 patients, the mean age was 56.96 years. The mean stone size was 3.19 cm (427 mm2). The mean S.T.O.N.E. score was 7.61, including 36 patients (24%) with scores ≥9. The mean operative time was 66.22 min, and the success rate of renal access creation in the first attempt was 88.7%. One hundred and forty (93.3%) patients were stone free. The mean decrease in Hemoglobin was 1.04 g/dL, and no patient needed a blood transfusion. Complications included transient hematuria (n = 13, 8.7%), bladder blood clot retention (n = 2, 1.3%), fever (n = 15, 10%) and sepsis (n = 2, 1.3%). Totally X-ray-free ultrasound-guided mini-PCNL in the GMSV position is feasible, safe and effective for patients with upper urinary tract stones, indicating the synergistic and complementary effects of the three novel techniques.

Definition of clinically insignificant residual fragments after percutaneous nephrolithotomy among urologists: a world-wide survey by EAU-YAU Endourology and Urolithiasis Working Group.

The aim of this article was to evaluate the current perception of urologists as to what size is considered as a clinically insignificant residual fragment (CIRF). A survey was globally distributed to the members of the Endourological Society via SurveyMonkey. A total of 385 participants responded to the survey on CIRF. Most participants considered 2 mm (29%) as CIRF threshold, followed by 3 mm (24%), 4 mm (22%), 0 mm (14%), 5 mm (8%) and 1 mm (3%). North American urologists considered CIRF to be smaller than urologists from Asia, Eurasia and South America, (p-values ≤0.001, 0.037 and 0.015 respectively). European urologists identified smaller CIRF in comparison to Asian urologists (p-value = 0.001). Urologists mainly using a pneumatic lithotripter accepted larger fragments as CIRF, compared to urologists mainly using ultrasonic devices or a combination of ultrasonic and pneumatic devices (p-value = 0.026 and 0.005 respectively). Similarly, urologists mainly performing X-Ray and ultrasound as post-operative imaging accepted larger fragments as CIRF in comparison to urologists mainly performing non-contrast computed tomography (p-value = 0.001). What is considered as CIRF varies between urologist from different continents and seems to be associated with the lithotripter used and the post-operative imaging modality of preference to assess treatment success.

Fibrin gel-assisted stone extraction in retrograde intrarenal surgery.

Small stone fragments inevitably resulted from breakage of a large stone are almost impossible to be fully extracted from the collecting system in current RIRS settings. While most of these clinically insignificant residual fragments (CIRFs) < 4 mm may pass spontaneously, increasing evidence suggests that these so called CIRFs may act as an origin for new stone formation and eventually lead to reintervention(1). Therefore, it is of paramount importance to achieve complete stone free status in the aim of improving patient's quality of life not only physically but also psychologically and economically(2).

Percutaneous Nephrolithotomy via a Middle Calyx Access Is Effective in the Treatment of Lower Pole Kidney Stones: A Single-Center Study

Purpose: To compare the efficacy of the middle calyx access (MCA) and lower calyx access (LCA) in the treatment of lower pole kidney stones. Materials and Methods: The data of patients with isolated lower pole kidney stones who underwent percutaneous nephrolithotomy via MCA or LCA between 2009 and 2019 were evaluated retrospectively. Pre-, peri-, and postoperative parameters of the groups (LCA group and MCA group) were compared. A value of p < 0.05 was considered significant. Results: A total of 601 patients with lower pole kidney stones were included in the study. LCA was performed for the initial tract in 400 patients, and MCA was performed in 201 patients. There were no significant differences in terms of age, gender, laterality, body mass index, previous operation history, stone burden, duration of fluoroscopy, and stone-free rate between the groups. Operation time was significantly longer in the LCA group (p = 0.041). In the LCA group, additional access was required in 50 cases, which was significantly higher than in the MCA group (p = 0.013). Clinically insignificant residual fragments (CIRF) were present in 28 patients (7%) in the first group (significantly higher vs. MCA: p = 0.044). There were no statistically significant differences in terms of overall complication and transfusion rates. Conclusions: MCA had superior outcomes in terms of operation time, CIRF rate, hemoglobin drop, and requirement of an additional tract compared to LCA. Further studies evaluating the efficacy of MCA in lower pole kidney stones should be performed to verify our results.

A Comparative Study Between Holmium Laser, Pneumatic Lithotripsy and Shock Pulse in Terms of Efficacy and Safety in Percutaneous Nephrolithotomy (PCNL): A Prospective Randomized Study

Background and Objectives Percutaneous nephrolithotomy (PCNL) occupies an essential place in the treatment of upper urinary tract calculi. PCNL also accomplishes higher stone-free rates and requires fewer auxiliary procedures than shock wave lithotripsy (SWL) and ureterorenoscopy (URS) for renal stones between 1–2 cm. There are different intracorporeal lithotripter devices available. This study aims to compare the efficacy and safety of holmium laser, pneumatic lithotripsy and Shock Pulse in PCNL. Materials and Methods A prospective randomized study was performed in Gauhati Medical College &amp; Hospital, Guwahati, Assam, India, between October 2016 to November 2018. Patients of renal calculi and upper ureteric calculi less than or equal to 2.5cms and functioning kidney on the ipsilateral side were included. 300 patients were randomized according to a random number generator. In the holmium laser, pneumatic and Shock Pulse groups’ number of patients was 96, 102, 102 respectively. Stone disintegration time (SDT), stone-free rate, failure rate, success rate, irrigant used, mean hematocrit drop were evaluated. Statistical analysis was done to compare and predict any significant difference. Results Patients were divided into groups depending on the lithotripter used: group A (n=96), group B (n=102), group C (n=102) were holmium laser, pneumatic lithotripsy, and Shock Pulse respectively. No significant difference in stone location (p=0.785),Hounsfield unit (p=0.115),complication rates between the groups. Stone free rate in laser, pneumatic lithotripter, and Shock Pulse were 81.25%, 67.65%, 82.35% (highest in Shock Pulse and lowest in the Pneumatic group) and failure rate were 6.25%, 14.7%, 5.89% respectively. A significant difference was found in terms of stone-free, success rate, clinically insignificant residual fragments(CIRF)and failure rates between the groups(p&lt;0.001). Irrigant requirement (litre/mm3) between the groups is statistically significant (p&lt;0.001) with the highest in Shock Pulse and lowest in the Pneumatic group. Mean hematocrit drop: 4.19%, 4.20%, 5.46% in Laser, Pneumatic and Shock Pulse respectively. No significant difference between Laser and Pneumatic group (p=0.907), but in Shock Pulse group it is significantly higher. (p&lt; 0.001) Conclusion Efficacy of energy sources used in PCNL for stone fragmentation vary in terms of stone clearance, failure rates, SDT, irrigant requirement and mean hematocrit drop. In our study, we found stone clearance signifi-cantly higher in Shock Pulse than Pneumatic and Laser groups. Stone fragmentation volume per unit time highest in Shock Pulse and lowest in Laser. Irrigant requirement highest in Shock Pulse group and compa-rable between Laser and Pneumatic group. The higher irrigant requirement in the Shock Pulse group may be the cause for higher hematocrit drop in this group. Complications between the groups are comparable.

Sheathless and fluoroscopy-free retrograde intrarenal surgery: An attractive way of renal stone management in high-volume stone centers

ObjectiveTo evaluate the efficacy and safety of sheathless and fluoroscopy-free flexible ureterorenoscopic laser lithotripsy (FURSL) for treating renal stones. MethodsBetween May 2015 and May 2017, 135 patients with renal stones treated with sheathless and fluoroscopy-free FURSL were prospectively evaluated. Our technique involved a semi-rigid ureteroscopic assessment of the ureter, and the guidewire was left in situ to railroad the flexible ureteroscope. A holmium laser was used to fragment and dust the stones; fragments were neither grasped nor collected. ResultsThe study population consisted of 135 patients including 85 males (62.96%) and 50 females (37.04%) with a mean age of 40.65 years (range: 3–70 years) were evaluated. The mean stone size was 17.23 mm (range: 8–41 mm). Complete stone-free status was achieved in 122 (90.37%) patients and clinically insignificant residual fragments (CIRF) in two (1.48%), while residual stones were still present in 11 (8.15%) patients. Postoperative complications occurred in 23 (17.4%) cases and were mostly minor, including fever in 17 (12.6%), pyelonephritis in four (3.0%), subcapsular hematoma in one (0.7%) and steinstrasse in one (0.7%). These complications were Clavien I-II, GI in 17 (12.6%) patients, GII in five (3.7%), and Clavien IIIb in one (0.7%). No major complications were observed. Stone size ≥2 cm, operative time ≥30 min, and lasing time ≥20 min were significantly associated with a higher rate of complications and lower stone-free rates upon univariate analysis (p<0.05). ConclusionSheathless and fluoroscopy-free FURSL are effective and safe for renal stone management, especially for stones under 2 cm in diameter. This process is a feasible option for avoiding sheath complications, which can protect surgeons from the negative effects of radiation.

Residual stone fragments: clinical implications and technological innovations.

To summarize the recent literature on the topic of residual stone fragments in particular novel developments in this field. The urological position towards residual fragments has shifted in recent years from observation, to active retrieval with innovative methods, to algorithm-based predictions of surgical outcomes. Novel technologies have been described to extract residual fragments through magnetism, a polyethylene endoscopic pouch and a biocompatible stone adhesive. In an effort to have a tighter grip over the outcome of residual fragments, artificial neural networks (ANNs) have been developed to accurately predict surgical outcomes in terms of stone clearance and secondary procedures. Growing evidence continues to show the term clinically insignificant residual fragments (CIRF) for residual fragments of 4 mm or less to be a misnomer. In fact, only a third of CIRF is spontaneously cleared from the kidney after surgery and may become a cause for reintervention being both costly and significantly affecting patients' well being. Several novel methods which have been developed to extract residual fragments require further in-vivo investigations to confirm their safety and efficacy. ANNs algorithms are increasingly being used to predict surgical outcomes in stone therapy and assist in preoperative patient counselling and decision-making.

Does Previous Failed Shockwave Lithotripsy Treatment Have an Influence on Retrograde Intrarenal Surgery Outcome?

Background: The prevalence of urolithiasis is nearly 20% and patients with urolithiasis constitute an essential part of the patients referred to the urology clinic. Many parameters should be considered for the management of renal stones and authors recommend extracorporeal shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotripsy (PNL), as treatment options. Among these techniques, SWL does not require general anesthesia, has 89% success rate for renal pelvic stones: 83% for upper caliceal stones, 84% for middle caliceal stones, and 68% for lower caliceal stones. In this study, we aimed to investigate whether the previously failed SWL treatment affects RIRS outcome. Methods: Patients who underwent RIRS for kidney stones between January 2012 and December 2017 in Diskapi Yildirim Beyazit Training and Research Hospital were reviewed retrospectively. Patients treated with primary RIRS (186 patients) were classified as Group 1. The outcomes of these patients were compared with those of 186 patients who underwent RIRS after failed SWL treatment using matched-pair analysis, and these patients were classified as Group 2. Results: The procedure success was defined as the sum of the stone-free and clinically insignificant residual fragments (CIRFs); final success rates were 90.3% and 91.9%, respectively. If we compare the final success rates, there was no statistically significant difference between both groups (P = .584). Conclusions: As a result, there is no negative effect of the previous unsuccessful SWL treatment on the RIRS success. Patients with CIRF should be followed up more carefully in terms of becoming symptomatic.

Flouroscopy-free technique is safe and feasible in retrograde intrarenal surgery for renal stones.

The aim of this study was to present outcomes of our patients who had undergone retrograde intrarenal surgery (RIRS) with fluoroscopy-free technique and evaluate the efficacy and safety of the technique. Between January 2013 and June 2015 the outcomes of 93 patients who had undergone RIRS with fluoroscopy-free technique were retrospectively evaluated. Our RIRS technique involved preoperative assessment of ureter by semi-rigid ureteroscope, inserting guidewire through semi-rigid ureteroscope, inserting ureteral access sheath over the guidewire with the visiual guidance of semi-rigid ureteroscope, passing flexible ureteroscope through the sheath, dusting the stone with holmium laser, rechecking the ureter with semi-rigid ureteroscope and inserting double J stent through semi-rigid ureteroscope. Low-dose computerized tomography scan was performed to all patients in postoperative first month and the results were classified as stone-free (absence of any fragment), clinically insignificant residual fragments (CIRF) (≤4 mm) and residual stone. Study population consisted of 62 (66.6%) male and 31 (33.3%) female patients with a mean age of 47.8±14 (range 14-93) years. Mean stone size was 14.7±5 (7-32) mm. Median operative time was 72 (30-125) minutes. Stone-free rate was achieved in 65 (69.9%) patients while CIRF was achieved in 13 (13.9%) and residual stones were detected in 15 (16.1%) patients. Five patients (5.37%) had minor complications, including hematuria and fever. No major complications were observed. Fluoroscopy-free technique is effective and safe technique in management of renal stone. Furthermore fluoroscopy-free technique can protect the surgeon from the negative effects of radiation.

MP33-08 PREDICTING FACTORS FOR COMPLICATIONS AND STONE CLEARANCE FOLLOWING PEDIATRIC MINI-PERCUTANEOUS NEPHROLITHOTOMY

INTRODUCTION AND OBJECTIVES: To detect predicting factors for complications and stone clearance following pediatricMiniperc METHODS: From January 2012 to December 2014, children ( 12 yrs) with renal calculi who underwent Miniperc were included (79 children). Nephroscopy was done using 9.5 Fr semirigid ureteroscope through 14 Fr renal access sheath with Holmium:YAG laser lithotripsy. Finally, a 10 Fr percutaneous nephrostomy (PCN) was inserted. Effects of different factors on complications and stone free rate (SFR) were compared using Chi square or Fischer exact tests. RESULTS: Mean age was 58.1 31.3 months (6-144) while stone size was 16.3 7.9 mm (5-49). 22 (27.8%) stones were 20 mm while 8(10.1%) stones were branching. Multiple stones were present in 25(31.6%) patients. Single puncture was used except in 4 patients (5.1%). Operative time was 64.7 28.5 min (25-180). Complications were bleeding (3.8%), blood transfusion (1.3%), renal pelvis perforation (2.5%), postoperative leakage from PCN tract (5.1%) and fever (17.7%). SFR after primary-Miniperc was 86.1%. Second-look Miniperc was required in 3.8% with SFR improvement to 89.9%. Auxiliary ESWL was performed for 6.3% with SFR improvement to 94.9%. If the 3 patients with clinically insignificant residual fragments (CIRF) were included, SFR would be 98.7%. SFR was significantly lower in children with 2 stones (p 1⁄4 0.011), with stone size 20mm (p 1⁄4 0.005), with grade 2-3 hydronephrosis (p 1⁄4 0.019), and when stones were in other sites than pelvis (p 1⁄4 0.042) (Table 1). Complication rate was not affected by sex, degree of hydronephrosis, side, number, size, shape or site of stones (Table 2). CONCLUSIONS: Miniperc has high SFR in children using 14 Fr sheath and 9.5 Fr ureteroscope with acceptable complications. Stone clearance is affected by the presence of 2 stones, size 20mm, and when stones were in other sites than pelvis. Source of Funding: none

Shock wave lithotripsy (SWL): outcomes from a national SWL database in New Zealand.

To present the national outcomes for New Zealand of over 9000 stone cases treated with SWL at 21 centres over a 20 year period. Stone cases treated with SWL on board the Mobile Medical Technology (MMT) vehicle between 19 June 1995 and 1 December 2014 were identified, and data collection undertaken prospectively for patient, stone and treatment characteristics, and retrospectively for treatment outcomes. The primary outcome was treatment success, defined as complete stone clearance or clinically insignificant residual fragments (CIRFs) of ≤4 mm. Secondary outcomes were stone free rate, complications and auxiliary procedures, and all statistical analyses were descriptive. 9538 stone cases (7769 patients) were included. The overall, cumulative success rate was 58.7%; this included 45.1% that were stone free and 13.5% in which there were CIRFs ≤4 mm. Success rates varied widely by stone size and location. Overall rates of urinary tract infection, perinephric haematoma, hospital admission and ureteral stent placement were 1.1%, 0.2%, 6.8% and 4.1%, respectively. Variations in SWL protocols across centres limits the overall reliability of our findings. SWL remains a low morbidity management option requiring careful patient selection. This study provides valuable data for patient counseling and the formation of evidence based guidelines in SWL. The MMT SWL service has demonstrated that is it possible to deliver a high volume specialist stone service without requiring patients to travel further for treatment.

Comparison of Extracorporeal Shock Wave Lithotripsy versus Ureteroscopy Holmium Laser Lithotripsy in the Management of Ureteral Stones: A Cost-effectiveness Analysis

Objective: To determine the better cost-effective treatment strategy for ureteral stones in a health district of Eastern Spain. Methods: A total of 180 patients were treated between June 2012 and December 2013 for ureteral stones using two different strategies (SWL as initial treatment and URS as rescue technique vs URS and laser lithotripsy (up to 2 procedures). We performed an economic evaluation through a cost effectiveness analysis comparing costs and outcome. We performed a differentiating model in patients with lithiasis less than 1 cm or equal to or larger than 1 cm. The effectiveness parameter was the stone free rate (SFR), defined as the absence of lithiasis fragments or the presence of clinically insignificant residual fragments (CIRFs) - less than 3 mm at the 3 month follow up. A decision tree was developed and a Monte Carlo simulation was performed to establish uncertainty. Results: The SWL as first line was equally or more effective and cheaper than URS as first line of treatment for ureteral stones regardless of location or size. The overall cost for SWL (plus URS as second line) was 1,445,86 € and its SFR was 99.7%, and 2,369,21 and 97.62% for URS group. After the Montecarlo sensitivity analysis, the SWL showed dominance or cost-effectiveness in the vast majority of times, for each position and size. Conclusions: SWL as first line of treatment was more efficient in terms of cost effectiveness than first line URS with Ho: YAG laser lithotripsy for ureteral stones. Given its level of stone clearance, a non-invasive, outpatient based treatment like lithotripsy should remain the first-line treatment option for ureteral stones

STPEDISET: A novel innovation for percutaneous nephrolithotomy in children

PurposeThe aim of this study was to report the outcomes of PCNL in patients in whom the Short and Thin Pediatric Set (ST PEDISET) had been used. MethodsData from 21 patients (11 boys and 10 girls) who underwent PCNL for renal stones using the ST PEDISET between April 2013 and February 2015 were analyzed retrospectively. The patients were evaluated by plane radiography and USG after surgery. ResultsIn total 21 children (11 boys and 10 girls) with a median age of 13months (range 5months to 4years) who underwent PCNL were included in the study. The median stone burden was 16mm (range 10–36mm). The success rate was 85.7%. Sixteen patients (76.2%) were stone free and two patients (9.5%) had clinically insignificant residual fragments (CIRF). The median length of hospital stay was 4days (range 2–9days). ConclusionsThe data of this study clearly show that the ST PEDISET is safe, effective and ergonomic for percutaneous nephrolithotomy in preschool-age children. This study indicates the need for randomized trials on larger cohorts to confirm these findings, and thus improve the surgical procedure.

Retrograde intrarenal surgery in the management of symptomatic calyceal diverticular stones: a single center experience.

To evaluate the outcome of RIRS in managing symptomatic calyceal diverticular as a minimally invasive option, we retrospectively reviewed the records of 43 patients who underwent RIRS from 2005 to 2014 for symptomatic calyceal diverticular stones. A month after the initial operation, the success rate was (81.4%, 35 patients) of which 21 (48.83%) patients were stone free and 14 (32.6%) patients had clinically insignificant residual fragments (CIRFs), and 90% patients were symptom free. Eight patients (16.6%) had significant residual fragments (>3 mm), five of them became completely stone free after the second procedure, other three patients were symptom free and underwent a routine follow-up. The final treatment success rate was 93.0%. The initial success rate in the lower calyx was significantly lower than the other calices (P = 0.040). In addition, the association between the stone size and the initial treatment success was significant (P = 0.036). There was no association between any of our other variables and the success rate. The mean first operative time was 60.95 ± 12.43 min (range 34-92). No major complication (Clavien III-V) occurred, although there were five minor complications (11.6%) (Clavien I-II). There were no admissions to intensive care or deaths in our series, the mean hospitalization time was 1.77 ± 0.80 days. The management of calyceal diverticular calculus with RIRS is highly effective and can be accomplished with low morbidity.

Clinically Insignificant Residual Fragments: Is It an Appropriate Term in Children?

To assess the outcome of clinically insignificant residual fragments (CIRFs) after shock wave lithotripsy (SWL) and percutaneous nephrolithotomy (PNL) in children. Sixty-one children with CIRFs diagnosed by noncontrast computed tomography (NCCT) 3 months after SWL and 1 month after PNL with documented follow-up ≥6 months were included in the study. Children were evaluated by urinalysis, urine culture, plain abdominal radiography, and urinary ultrasonography or noncontrast computed tomography. Outcomes measured were fragment regrowth, spontaneous fragment passage, and secondary interventions. A clinically significant outcome was defined as the need for secondary intervention for development of complications or regrowth of the residual fragment (RF). The study included 42 boys and 19 girls with mean age of 6.2 years (range 1-14). After a median follow-up of 18 months, 16 children (26.2%) passed RF spontaneously. Regrowth of the RF was observed in 15 children (24.6%), and in 4 children (6.6%) the RF (of the same original size) slipped to the ureter and was treated by ureteroscopy. Therefore, a clinically significant outcome occurred in 31.2% of children with RF. Children with history of stone disease were more likely to develop clinical significance with time (HR, 4.38; 95% CI, 1.37-14; P = .013) CONCLUSION: The term CIRF is not appropriate for all children with post-SWL and -PNL fragments, as one-third of patients have had fragments that became clinically significant. History of stone disease was the only predictor of clinical significance.

MP28-20 COMPARISON OF FLEXIBLE URETERORENOSCOPY AND MINI PERCUTANEOUS NEPHROLITHOTOMY IN TREATMENT OF LOWER CALYCEAL STONES SMALLER THAN 2 CM

You have accessJournal of UrologyStone Disease: Surgical Therapy II1 Apr 2015MP28-20 COMPARISON OF FLEXIBLE URETERORENOSCOPY AND MINI PERCUTANEOUS NEPHROLITHOTOMY IN TREATMENT OF LOWER CALYCEAL STONES SMALLER THAN 2 CM Mehmet Fatih Akbulut, Onur Kucuktopcu, Emre Kandemir, Erkan Sonmezay, Abdulmuttalip Simsek, Faruk Ozgor, Murat Binbay, Ahmet Yaser Muslumanoglu, and Zafer Gokhan Gurbuz Mehmet Fatih AkbulutMehmet Fatih Akbulut More articles by this author , Onur KucuktopcuOnur Kucuktopcu More articles by this author , Emre KandemirEmre Kandemir More articles by this author , Erkan SonmezayErkan Sonmezay More articles by this author , Abdulmuttalip SimsekAbdulmuttalip Simsek More articles by this author , Faruk OzgorFaruk Ozgor More articles by this author , Murat BinbayMurat Binbay More articles by this author , Ahmet Yaser MuslumanogluAhmet Yaser Muslumanoglu More articles by this author , and Zafer Gokhan GurbuzZafer Gokhan Gurbuz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1243AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To compare the outcomes of flexible ureterorenoscopy and mini percutaneous nephrolithotomy in the treatment of lower calyceal stones smaller than 2 cm. METHODS Patients who underwent flexible ureterorenoscopy (F-URS) and mini percutaneous nephrolithotomy (miniPNL) for the treatment of lower calyceal stones smaller than 2 cm between March 2009 and February 2014 were retrospectively evaluated. Each group included 20 patients. All patients were preoperatively diagnosed with intravenous pyelography or computed tomography. Operations which are resulted as clinically insignificant residual fragments (CIRF) or completely stone free were evaluated as successful operations. Comparison of final results was performed according to the percentages of successful operations. RESULTS Success rates for F-URS and miniPNL at post operative early days were 80% and 85% respectively. Post operative first month success rates were 85% and 90% for F-URS and miniPNL patients respectively. Operation time, fluoroscopy time and hospitalisation time for F-URS and miniPNL patients were 63.10 minutes, 2.4 minutes, 28.3 hours and 105.16 minutes, 7.05 minutes, and 76.8 hours, respectively. All three parameters were significantly shorter among the F-URS group (p<0.001). Peroperative haemoglobin drop did not differ significantly (p=0.618). A comparison of complications according to the Clavien classification demonstrated significant differences between the groups (p=0.019). More patients in the F-URS groups developed fever that required antibiotics, and more patients in the miniPNL group required ureteral double J (DJ) catheter insertion under general anaesthesia. CONCLUSIONS Although both F-URS and miniPNL have similar success rates for the treatment of lower calyceal stones, F-URS appears to be more favourable due to shorter fluoroscopy and hospitalisation times. Table 1. Preoperative patient demographics F-URS miniPNL All Patients P Value Number 20 20 40 Gender 0.311 Male 12 15 27 Female 8 5 13 Age (years) 45.75±12.98 39.84±17.815 42.87±15.60 0.242 BMI (Kg/M2) 28±8.19 27.22±4.27 27.90±6.48 0.317 Stone area (mm2) 191.65±52.50 202.75±97.50 197.20±77.50 0.657 Opacity 0.292 Opaque 17 19 36 Non-opaque 3 1 4 Hydronephrosis 0.149 0 7 2 1 7 13 2 2 3 3 3 1 4 0 1 Side of surgery 0.022 Left 9 16 25 Right 11 4 15 History of renal stone surgery 0.507 Primary 14 12 26 Secondary 6 8 14 BMI: Body mass index Table 2. Comparison of surgical results between the operation groups F-URS miniPNL P Value Operation time (min) 63.10±27.12 105.16±38.25 <0.001 Fluoroscopy time (min) 2.4±1.39 7.05±4.26 <0.001 Hospitalisation time (hours) 28.30±33.67 76.80±29.75 <0.001 Haemoglobin drop (mg/dl) 0.38±0.97 0.15±1.78 0.618 Stone fragmentation device 0.07 No fragmentation 0 1 Laser 20 14 Laser pneumatic 0 1 Ultrasonic 0 4 Clavien score 0.019 1 0 2 2 4 0 3A 0 0 3B 1 6 4 0 0 5 0 0 Result 0.11 CIRF 7 2 Residual stone 4 3 Stone-free 9 15 CIRF: Clinically insignificant residual fragments © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e318 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mehmet Fatih Akbulut More articles by this author Onur Kucuktopcu More articles by this author Emre Kandemir More articles by this author Erkan Sonmezay More articles by this author Abdulmuttalip Simsek More articles by this author Faruk Ozgor More articles by this author Murat Binbay More articles by this author Ahmet Yaser Muslumanoglu More articles by this author Zafer Gokhan Gurbuz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...