Intrarenal Stones Research Articles

Tip bendable suction ureteral access sheath versus traditional sheath in retrograde intrarenal stone surgery: an international multicentre, randomized, parallel group, superiority study

Retrograde intrarenal surgery (RIRS) is the main treatments for upper urinary tract stones. The Ureteral Access Sheath (UAS) serves as a supplementary tool, facilitating direct kidney access during RIRS. High quality of evidence comparing tip bendable suction ureteral access sheath (S-UAS) with traditional UAS in RIRS for the treatment of renal and ureteral stones is lacking. The purpose of the study is to compare the efficacy and safety of S-UAS with traditional UAS in RIRS for the treatment of renal or ureteral stones ≤30mm. An international, multicenter, and superiority randomized controlled trial included 320 intention-to-treat patients across 8 medical centers in China, the Philippines, Malaysia and Turkey from August 2023 to February 2024. The inclusion criteria were patients ≥18 years old with renal or ureteral stones ≤30mm. RIRS was performed using either S-UAS or traditional UAS. The primary outcome was the immediately stone-free rate (SFR). Secondary outcomes included SFR 3 months after operation, operating time, hospital stay, auxiliary procedures, complications (using the Clavien-Dindo grading system), and improvement in the Quality of Life (QoL) score. Differences between proportions [risk difference (RD)]/means [mean difference (MD)] and 95% confidence intervals (CI) were presented. This study is registered at ClinicalTrials.gov: NCT05952635. The S-UAS group demonstrated a significantly higher immediately SFR (81.3% versus 49.4%; RD 31.9%; 95% CI 22.5%-41.7%; p=0.004) compared to the traditional UAS group, as determined by the one-side superiority test. Additionally, the S-UAS group exhibited a higher SFR at 3 months post-operation (87.5% versus 70.0%; RD 17.5%; 95% CI 8.7%-26.3%; p<0.001), lower postoperative fever rate (RD-11.9%; 95% CI-18.7% to-4.9%; p<0.001), reduced use of stone baskets (RD-70.6%; 95% CI-77.8% to-63.5%; p<0.001), and better QoL improvement (MD 7.25; 95% CI 2.21-12.29; p=0.005). No statistically significant differences were observed in operation time, hospital stay, or the need for second-stage RIRS. In RIRS for upper urinary tract stones ≤30mm, S-UAS exhibited superior performance compared to traditional UAS, demonstrating higher SFR, reduced postoperative fever rate, and improved QoL outcomes. S-UAS emerges as a prudent and advantageous alternative to traditional UAS for RIRS. National Natural Science Foundation of China and Guangdong Province, and Zhejiang Medicine and Health Program.

Is Totally Tubeless Percutaneous Nephrolithotomy a Safe and Efficacious Option for Complex Stone Disease?

Background: Percutaneous nephrolithotomy is the gold standard treatment for large, complex intrarenal stones. Historically, this was performed using a nephrostomy tube (PCN) and/or internalized ureteral stent at the end of the procedure. However, totally tubeless nephrolithotomy (tt-PCNL) is a novel technique where no tubes (no stent nor nephrostomy tube) are left post-operatively. We review the literature on this subject regarding peri-operative outcomes, post-operative outcomes, and potential complications of the procedure, discuss our technique, and make recommendations on implementation for centers not currently utilizing the procedure. Materials and methods: We performed a comprehensive search of the literature on totally tubeless nephrolithotomy using MEDLINE database search. Our search included prior review articles, meta-analyses, systematic reviews, primary research articles, case reports, and case studies. Results: In comparison to prior approaches where a stent or nephrostomy tube is placed, tt-PCNL has a similar complication rate and better post-operative outcomes. Totally tubeless PCNL has similar operative times and similar changes in hemoglobin. However, it had shorter length of stays across all studies. The mean difference in length of stay in the studies reviewed was 1.96 days. Additionally, tt-PCNL had decreased post-operative analgesic requirements and pain scores. Conclusions: This review highlights totally tubeless percutaneous nephrolithotomy as a safe and feasible surgical technique with improved outcomes in properly selected patients.

Sedation vs. general anesthesia in stone ureteroscopy: Comparison of efficacy and safety, a post COVID-19 report

IntroductionUreterorenoscopy (URS) for ureteral or renal stones is traditionally performed under general anesthesia (GA). Sedation is an alternative to GA, allowing control of the level of consciousness, spontaneous ventilation, and faster recovery. Our aim was to compare sedation and GA for patients undergoing ureterorenoscopy. Endpoints were stone-free rate (SFR) and complication rates. MethodMonocentric comparative retrospective study including all consecutive ureterorenoscopies for ureteral or renal stone. The inclusion period was dichotomized in two 6-months periods due to the COVID-19 pandemic: from January 1 to July 1, 2019 (URS under GA) and from January 1 to July 1, 2021 (URS under GA or sedation). Stone-free (SF) status was defined as the absence of stone or fragment>4mm after the first ureterorenoscopy. Complication rates were assessed according to the Satava (perioperative complications) and Clavien-Dindo (postoperative complications) classifications. Statistical analysis was performed by Chi-square test. ResultsA total of 185 patients were included for a total of 206 ureterorenoscopies; 82 underwent ureterorenoscopy under GA and 103 under sedation. The median stone size was 10 [7–16] mm. In all, 150 (81%) patients had at least one intrarenal stone. The SFR was similar between the two groups (67% GA group, 69% sedation group, P=0.912). In the sedation group, the mean SFR in ureter was 83.7% vs. 92.5% in the GA group. In renal cavities, the mean SFR was 46.4% in the sedation group vs. 42.5% in the GA group. Satava grade I, IIa, and IIb complications were 5 (6%), 5 (6%), and 1 (1%) in the GA group and 6 (6%), 1 (1%), and 3 (3%) in the sedation group, respectively (P=0.214). The grade I, II, III, and IV Clavien complications were 6 (7%), 3 (4%), 0 (0%), and 2 (2%) in the GA group and 6 (6%), 4 (4%), 1 (1%), and 4 (4%) in the sedation group, respectively (P=0.928). ConclusionOur post COVID-19 study showed no difference in efficacy and safety between ureterorenoscopy under sedation and GA for patients with renal stones. Our results confirm the interest of the sedation procedure, particularly in the context of outpatient surgery. Level of evidence4.

Cumulative sum analysis of the learning curve for retrograde intrarenal stone surgery in newbie surgeons.

This study investigated the learning curve of retrograde intrarenal surgery (RIRS) in patients with medium-sized stones using cumulative sum analysis (CUSUM) to evaluate the competence and proficiency of three new surgeons during their first RIRS procedures. We conducted a retrospective review of 227 patients from 2019 to 2022 at a single institution. The patients were divided into four groups based on the operating surgeon: tutor surgeon (85 patients), newbie surgeon A (21 patients), newbie surgeon B (85 patients), and newbie surgeon C (36 patients). Patients had one or multiple stones with the largest stone diameter fell within the range of 10-30mm. Fragmentation efficacy was calculated as "removed stone volume (mm3) divided by operative time (minutes)." CUSUM analysis monitored changes in fragmentation efficacy and validated surgical outcomes. No statistically significant differences were observed in the total stone volume, maximum stone size, or total operation time between the three newbie surgeons and the tutor surgeon. The mean fragmentation efficacy value was comparable among the newbie surgeons, but significantly different from that of the tutor surgeon. The minimum acceptable fragmentation efficacy level was set at 25.12mL/min, based on the tutor's average value. The CUSUM curves for the three surgeons initially remained relatively flat until Cases 12-15, after which they increased and eventually plateaued. Stone-free rates and postoperative complications did not differ significantly among the surgeons. Learning curve analysis for the three newbie surgeons indicated that approximately 12-15 cases were required to reach a plateau.

Efficacy of Aspiration-Assisted Ureteral Access Sheath (ClearPETRA) in Retrograde Intrarenal Surgery.

Backgrounds: In the renal intrarenal stone surgery (RIRS) procedure, ureteral access sheath (UAS) is still used in the majority of surgeries to both protect the flexible ureteroscope (FURS) and reduce intrarenal pressure. ClearPETRA is a new UAS that has an integrated aspiration port. We aimed to evaluate the clinical outcomes and effectiveness of Aspiration-Assisted UAS (ClearPETRA) in the RIRS procedure. Methods: One thousand six hundred twenty patients who underwent RIRS between January 2021 and January 2024 were evaluated retrospectively and 512 patients were included in the study. According to stone size, patients with stones less than 2 cm and those with stones between 2 and 3 cm were analyzed separately. Patient's demographic data, stone size, body mass index, Extracoporeal Shockwave Lithotripsy (ESWL) history, stone side, stone density (Hounsfield Unit), operation time, stone-free rate (SFR), and the number of patients with sepsis were recorded. SFR was evaluated with kidney urinary bladder 3 months after surgery for opaque calculi. Nonopaque calculi patients were evaluated with noncontrast computed tomography 3 months after surgery. In the postoperative evaluation, patients with stones less than 4 mm were evaluated as SFR. P value of <0.01 was considered statistically significant. Results: Patient's demographic data, stone characteristics, and history of ESWL were similar in the ClearPETRA and UAS groups (P > .05). A total of 328 patients who underwent RIRS for stones less than 2 cm were included (80 ClearPETRA, 248 UAS). Length of hospital stay, operation time, SFR, secondary intervention, or postoperative sepsis (P ≥ .01) were similar in both groups. The incidence of postoperative fever was statistically significantly lower in the ClearPETRA group (P = .006). A total of 184 patients who underwent RIRS for stones between 2 and 3 cm were included (42 ClearPETRA, 142 UAS). In the ClearPETRA group, operation time was statistically significantly shorter (P = .002), SFR was statistically significantly higher (P = .003), and the number of fever and sepsis were statistically significantly less (P = .003 and 0.002, respectively). Conclusion: We found that ClearPETRA reduces the likelihood of postoperative fever after RIRS surgeries. Moreover, we can say that the use of ClearPETRA in RIRS, especially for stones larger than 2 cm, reduces the operation time, increases the SFR, and also reduces sepsis rates.

Flexible ureteroscopy and laser lithotripsy in unilateral multiple renal stones

Background and Objectives: To identify the factors contributing to stone-free rates and postoperative complications of flexible ureteroscopy and laser lithotripsy in unilateral multiple renal stones. Methods: A total of 20 patients had retrograde intrarenal surgery procedures to treat unilateral multiple renal stones, less than 50 mm collectively were reviewed from May 2021 to December 2021. Stone numbers were calculated, and stone size was measured as the cumulative stone diameter of all intrarenal stones. The clinical insignificant residual stones were defined as the absence of stone fragments &lt;4 mm in the kidney at the end of the procedures. Baseline patient characteristics, operation time, hospital stay, stone-free rates, and complications were recorded. Results: Retrograde intrarenal surgery was performed on 20 patients (12 males and 8 females). The overall success rate was 80%. Depending on the sizes of the stones, patients with stones &lt;20 mm had a stone-free rate of 100% (10/10 patients) and patients with stone size? 20mm had a stone-free rate of 60% (6/10) with a (p &lt; 0.003). The number of stones per renal unit was two in 13 patients with a stone-free rate of (92.3%), three in 7 patients, and a stone-free rate was (57.1%) with a (p= 0.06). Postoperative complications were encountered in 4 patients (20%), and all were treated conservatively. Conclusions: Retrograde intrarenal surgery provides a satisfactory stone-free rate with a low complication rate when treating multiple renal stones. However, the success rate, stone-free rate, and the number of sessions significantly depend on the size and the number of stones.

Safety and feasability of ureteroscopy for pediatric stone, in children under 5 Years (SFUPA 5): A French multicentric study

Ureteroscopy (URS) can be proposed as first-line therapy for the management of pelvic stones from 10 to 20mm and for lower ureteric stones in children. However, little is known about the success and the morbidity of URS in young children. Ureteroscopic treatment may present matters in young children because of the small size of the pediatric kidney and the small size of the collecting system. To assess safety and efficacy of URS for the treatment of urinary stones in children aged of 5 years or less. After the institutional ethical board approval was obtained, we conducted a retrospective, analytic, multicentric study that included all URS performed between January 2016 and April 2022 in children aged of 5 years or less. In this non-comparative case series, anonymized pooled data were collected from 7 tertiary care centers of pediatric patients. Endpoints were the one-session SFR at 3 months and per and postoperatives complications. Descriptive statistics were applied to describe the cohort. Eighty-three patients were included. For them, 96 procedures were performed at the median age of 3.5 years (IQR: 0.8-5) and median weight of 14Kg (6.3-23). Median stone size was 13mm (4-45). There were 65 (67 %) renal stones treated with flexible URS, most of which were in the renal pelvis (30 %) and in the lower calix (33 %). A ureteral access sheath was used in 91% procedures. Preoperative ureteral stent was placed in 52 (54 %) of patients. None of patients had ureteral dilatation. The single-session SFR was 67.4 % (56.3 and 89.2% for flexible URS and semi-rigid URS respectively) and children require 1.4 procedures to achieve complete stone clearance. The overall complication rate was 18.7 %, most of them were minor (Clavien I-II). Intraoperative perirenal extravasation (Clavien IIIb) due to forniceal rupture was documented in 6.2% of cases, related to an increased intrapelvic pressure (IPP) performed in a closed pelvicalyceal system. Pediatric urologists should be aware of forniceal rupture based on the presence of extravasation of contrast during endourological procedures especially when they have difficulties to reach lower caliceal stone in small patient. URS in patients aged of 5 years or less, is a complex minimally invasive procedure with reasonable efficacy and low morbidity. Intrarenal stones treated by RIRS in young children carries the risk of additional procedures to complete stone clearance.

Is There Any Effect of Retrograde Intrarenal Stone Surgery on Renal Functions in Childhood?

Purpose In this study, we aimed to demonstrate whether retrograde intrarenal stone surgery (RIRS) performed due to renal stones during the childhood period has any detrimental impact on renal functions. Materials and methods We retrospectively analyzed 121 patients aged 2 to 16 years who underwent RIRS for renal stones between March 2018 and February 2023. Data were available for 41 patients. The estimated glomerular filtration rate (eGFR) was computed using the modification of diet in renal disease (MDRD) formula on the day preceding the surgery and the third month after the surgery. We employed the National Kidney Foundation's chronic kidney disease (CKD) classification to categorize the glomerular filtration rate (GFR) into five groups. Preoperative and postoperative eGFR values of pediatric patients were compared by analyzing changes in CKD groups. Results Of the patients included in the study, 21 (51.2%) were male, while 20 (48.8%) were female children. No significant difference was found between the preoperative median eGFR and the postoperative median eGFR values (p=0.958). In the 3rd month after surgery, it was observed that 5 (12.1%) patients showed an improvement in their CKD stage, while deterioration was noted in 1 (2.4%) patient. Although a negative correlation was observed between the median eGFR change and both the operation time and the stone volume in Pearson correlation analysis, it was determined that this change did not create a significant difference (p=0.213 and p=0.295, respectively). Conclusion Stone surgery conducted with RIRS appears to yield positive outcomes on kidney function in the pediatric population. Nevertheless, being particularly attentive to patients with prolonged operation times and larger stone volumes is essential.

Ten-Year Sepsis Rates Comparing Extracorporeal Shock Wave Lithotripsy and Ureterorenoscopic Laser Lithotripsy in an Australian Population

ObjectivesTo compare the rate and predictors of septic complications after shock wave lithotripsy (SWL) and flexible ureteroscopy and laser lithotripsy (FURS) in an Australian population.MethodsHospital admission data were extracted from the Victorian Admitted Episodes Dataset (VAED) regarding all elective admissions for SWL and FURS for treatment of intrarenal stones from 2009 to 2018, inclusive. Sepsis was defined by the ICD-10 diagnostic code, A41.ResultsThere were 13 154 inpatient episodes analysed, comprising SWL (6033) and ureterorenoscopic laser lithotripsy (7121). Males made up 67.43% of SWL patients and 63.34% of FURS patients. Median age was 57 years in both groups. Median American Society of Anesthesiologists physical status classification grade (ASA grade) was 2 for both groups, but proportionally more FURS patients were ASA grade 3 to 4 (P &lt; 0.001). Postoperative sepsis was more common in the FURS group (1.43% vs. 0.03%), as was intensive care unit admission (1.00% vs. 0.10%). Average length of stay was longer for FURS (1.43 days vs. 1.06 days). There were 4 inpatient deaths, all from the FURS group. FURS procedure, female sex, and a higher ASA grade were each independent predictors of sepsis.ConclusionsFURS may have a significantly higher relative risk of postoperative sepsis than SWL in high-risk patients as determined in this study. While overall risk is low, higher comorbidity (ASA grade 3 or 4) and female sex were independent predictors of sepsis. For these patients in particular, and when clinically appropriate, SWL may be considered as a potentially safer alternative to FURS.

Comparison of the efficacy of thulium fiber laser and holmium laser lithotripsy in the treatment of upper urinary tract stones

Objective: To compare the efficacy of thulium fiber laser (TFL) and holmium laser (HL) in the treatment of upper urinary tract stones. Methods: A total of 76 patients diagnosed with upper urinary tract stones by radiographic examination and who required ureteroscopy lithotripsy or retrograde intrarenal stone surgery were prospectively enrolled from the Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine between January 2022 and June 2022. Patients were divided into TFL group (n=38) and HL group (n=38) in a 1∶1 ratio according to the randomization schedule. The perioperative outcomes and stone-free rate of two groups were recorded and compared. Results: Finally, the clinical data of 71 patients were completely collected, including 55 males and 16 females, with a mean age of (45.7±14.1) years old. There were 36 patients in TFL group and 35 patients in HL group, and there was no significant difference in age, body mass index, gender, Charlson comorbidity index, stone site, stone location, stone size and stone density between two groups (all P>0.05). All the surgeries were successfully performed with no intraoperative complications. There were no significant differences between the two groups in terms of operation time, stone displacement during lithotripsy, visual field clarity, changes in hemoglobin, leukocyte, and C-reactive protein, and length of postoperative hospital stay (all P>0.05), but the laser action time[M (Q1,Q3)] in the TFL group was 30.0 (20.0, 48.8)s, which was significantly shorter than that in the HL group [90.0 (50.0, 120.0)s, P<0.001]. The stone-free rates of TFL group and HL group were 97.2% (35/36) and 88.6% (31/35), and there was no significant difference (P=0.337). The postoperative complication incidences of TFL group and HL group were 36.1% (13/36)and 22.9% (8/35), respectively, and the difference was not significant either (P=0.221). For ureter stones, the laser action time in TFL group was 22.5 (20.0, 43.8)s, which was significantly shorter than that in HL group [80.0 (50.0, 120.0)s, P<0.001]. For stones with maximum diameter≤10 mm, the laser action time in TFL group was 20.0 (10.0, 25.0)s, which was significantly shorter than that in HL group [50.0 (40.0, 80.0)s, P<0.001]. For stones with maximum diameter>10 mm, the laser action time in TFL group was 60.0(42.5, 180.0)s, which was significantly shorter than that in HL group [180.0(120.0, 210.0)s, P=0.035]. For stones with density≤1 000 CT, the laser action time in TFL group was 30.0 (20.0, 45.0)s, which was significantly shorter than that in HL group [95.0 (47.5, 120.0), P=0.001]. For stones with density>1 000 CT, the laser action time in TFL group was 30.0 (20.0, 90.0)s, which was significantly shorter than that in HL group [80.0 (55.0, 180.0)s, P=0.033]. Conclusion: TFL lithotripsy is an effective and safe surgical procedure for the treatment of upper urinary tract stones, with similar clinical efficacy but shorter laser action time compared to HL lithotripsy.

Efficacy and Safety of Holmium Laser Lithotripsy for Renal Calculi in Retrograde Intrarenal Surgery: A Comparative Study in Libyan Patients

Background Kidney stones are a common problem that can be treated by different surgical methods. The choice of treatment depends on the stone and patient characteristics and the local resources and skills of the urologists. Aim The aim of this study was to evaluate the outcomes regarding the safety and effectiveness of retrograde intrarenal surgery (RIRS) using holmium laser lithotripsy for kidney stones sizes of less than or equal to 20, and more than 20 mm. Methods The study was conducted on 54 patients with renal calculi at a single center using RIRS and holmium lithotripsy from April 2022 to April 2023. Stone size was calculated by summing up the diameters of all renal calculi, and stone-free rate (SFR) was defined as no stone or stone fragment less than 1 mm in the kidney. Results are described as mean ± standard deviation, frequency, and percentages. Chi-squared or unpaired t-tests are used for comparison between different groups as appropriate. A p-value less than 0.05 is considered significant. Results The mean intrarenal stone size was 17.8 ± 7.6 mm, with a significant difference in stone size less than or equal to 20 mm and stone size more than 20 mm (19 ± 4.7 and 35 ± 4 mm, respectively). The main operation time was 66 ± 36.5 minutes, with significantly longer operation time for patients with kidney stones more than 20 mm (94.9 ± 34.5 vs. 49 ± 26 for stone size ≤20 mm). There was no difference in the length of stay after operation between the two different stone sizes. The overall immediate SFR was 64.4%, where stone size less than or equal to 20 mm showed a significantly higher SFR (83%) than SFR for stone size more than 20 mm (31%). This SFR increased to 91.1% 1 month later, with 100% clearance for stones size less than or equal to 20 mm compared with only 68% for stones size more than 20 mm. The overall complication rate was 9.2%, most of them were due to urinary tract infections (5 cases) that required intravenous antibiotics. Stone size had no significant effect on the complication rate. There was no significant difference in SFR between lower calyceal stone and other sites of stone. Conclusion RIRS combined with holmium laser lithotripsy is a valuable treatment option for patients with renal stones particularly for patients with stones size of less than or equal to 20 mm with a relatively low rate and severity of complications.

MP23-19 LESSONS LEARNT FROM A MULTICENTER SERIES OF 400 CASES ON THE UTILITY OF PRE-STENTING FOR PEDIATRIC RETROGRADE INTRA RENAL SURGERY (RIRS)

You have accessJournal of UrologyCME1 Apr 2023MP23-19 LESSONS LEARNT FROM A MULTICENTER SERIES OF 400 CASES ON THE UTILITY OF PRE-STENTING FOR PEDIATRIC RETROGRADE INTRA RENAL SURGERY (RIRS) Ee Jean Lim, Stefania Ferreti, Anna Bujons, Olivier Traxer, Danielle Castellani, Yesica Quiroz, Deepak Ragoori, Tanuj Paul Bhatia, Chandra Mohan Vaddi, Claudia Gatti, Khi Yung Fong, Yiloren Tanidir, Bhaskar Kumar Somani, Anil Shrestha, and Vineet Gauhar Ee Jean LimEe Jean Lim More articles by this author , Stefania FerretiStefania Ferreti More articles by this author , Anna BujonsAnna Bujons More articles by this author , Olivier TraxerOlivier Traxer More articles by this author , Danielle CastellaniDanielle Castellani More articles by this author , Yesica QuirozYesica Quiroz More articles by this author , Deepak RagooriDeepak Ragoori More articles by this author , Tanuj Paul BhatiaTanuj Paul Bhatia More articles by this author , Chandra Mohan VaddiChandra Mohan Vaddi More articles by this author , Claudia GattiClaudia Gatti More articles by this author , Khi Yung FongKhi Yung Fong More articles by this author , Yiloren TanidirYiloren Tanidir More articles by this author , Bhaskar Kumar SomaniBhaskar Kumar Somani More articles by this author , Anil ShresthaAnil Shrestha More articles by this author , and Vineet GauharVineet Gauhar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003248.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retrograde intrarenal surgery (RIRS) is an option for pediatric kidney stone upto 1 cm in EAU guidelines and many urologist do RIRS for >1 cm stones as well if they have sufficient experience. We aim to assess the outcomes of pre-stenting versus non-pre-stenting in a pediatric population undergoing RIRS for intrarenal stones in different age groups and locations. METHODS: Data collected on Children/adolescents with kidney stones undergoing RIRS in 9 centers between 2015-2020 were retrospectively reviewed. Exclusion criteria: ureteral lithotripsy, bilateral procedures. Stone-free status was evaluated at 3-month and deemed as a single residual fragment (RF) ≤2 mm/absence of multiple fragments. Patients were divided into two groups (Group 1 no pre-stenting , Group 2 pre-stented). Student’s, Chi-square and Fisher’s exact test was used to assess difference between groups. Univariable and multivariable logistic regression analysis were performed to predict RF. Statistical signicance: p-value <0.05. RESULTS: 389 children/adolescents were included (192 patients in Group 1). Pre-stented patients were younger compared with non-presented (mean age 8.30±4.93 vs 10.43±4.30 years, p<0.001). There were no differences in stone characteristics (number, size, locations). Lasing and total surgical time were similar. Urinary tract infections (Clavien grade 2) were more prevalent in Group 2 (10.7%) compared to Group 1 (3.7%, p=0.016). Sepsis (Clavien grade 4) occurred in 2.1% of patients in Group 2 and no patient in Group 1 (p=0.146). 30.7% patients in Group 1 and 26.4% in Group 2 had RF (p=0.322). Multivariate logistic regression analysis showed that stone size was associated with RF (OR 1.20 95% CI 1.08-1.36, p=0.001). CONCLUSIONS: RIRS showed similar stone-free rate in pre and non-pre-stented children/adolescents, In this multicenter study, we found that preoperative positioning of ureteral stent had no effect in clearing stones but a higher incidence of postoperative infections. Whilst routine pre-stenting cannot be recommended it becomes imperative that the child's guardian is counseled appropriately about pros and cons of prestenting including need for additional anaesthesia. Source of Funding: NIL © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e314 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ee Jean Lim More articles by this author Stefania Ferreti More articles by this author Anna Bujons More articles by this author Olivier Traxer More articles by this author Danielle Castellani More articles by this author Yesica Quiroz More articles by this author Deepak Ragoori More articles by this author Tanuj Paul Bhatia More articles by this author Chandra Mohan Vaddi More articles by this author Claudia Gatti More articles by this author Khi Yung Fong More articles by this author Yiloren Tanidir More articles by this author Bhaskar Kumar Somani More articles by this author Anil Shrestha More articles by this author Vineet Gauhar More articles by this author Expand All Advertisement PDF downloadLoading ...

OUTCOMES AND SAFETY OF RETROGRADE INTRA RENAL SURGERY FOR RENAL STONES

Background: Renal stones are one of the most common urological problems requiring surgical interventions. Retrograde intra-renal surgery is a minimally invasive surgical technique with minimal complications and a good stone-free rate. In the present study we aimed to assess the outcomes and safety of retrograde intrarenal surgery. Methods: A retrospective study was performed at Chitwan Medical College Teaching Hospital in the span of two years from Dec 2019 to Nov 2021. Patient demographics; stone burden, stone density, and location were collected from the medical records and evaluated. The data was collected in a proforma which was then entered into SPSS version 20. The data was presented in form of frequency and percentage. Results: One hundred and seventy patients were subjected to retrograde intrarenal surgery, out of which 32 were converted to mini- percutaneous nephrolithotripsy, 12 were presented and total of 126 were subjected to retrograde intrarenal surgery. The major complications were pyrexia in 21(16.67%) patients followed by hematuria in 4(3.17%) patients, and sepsis in 2(1.58%) patients. The stone-free rate was 94.4%. 2 (1.58%) patients underwent mini- percutaneous nephrolithotripsy and5 (3.96%) of them showed stones of varying size 2-6mm, non-obstructive with none of cases planned for staged retrograde intrarenal surgery. Conclusions: Primary Retrograde intrarenal surgery is the safe and effective treatment for the intrarenal stones.

Assessment of factors influencing operating time during retrograde intrarenal surgery for renal stone in tertiary care hospital of Nepal

Retrograde intrarenal surgery (RIRS) is an effective and safe method for the management of intrarenal stone showing high stone-free rates. Its main advantage is decrease in operative morbidity for the patient, as well as a faster recovery. The current study aimed to study the factors influencing operating time during retrograde intrarenal surgery for renal stone in tertiary care hospital. It is an observational descriptive cross sectional study using purposive sampling method which was conducted among 188 patients who underwent retrograde intrarenal surgery (RIRS) for management of nephrolithiasis in Department of Urology of B&amp;B hospital, Lalitpur, Nepal. The baseline information of the factors affecting operating time were obtained like age, gender, site of renal stone, prestented or not, body mass index (BMI), ureteral access sheath (UAS) use, stone volume and stone density. The mean operating time was high in renal stone with calcium ammonium urate composition. On linear regression analysis, operative times significantly increased with greater stone volumes and also pre-stenting and ureteral access sheath use did significantly difference on operative time. It revealed stone volume to be the most significant predictor of operative time. Thus, the present study provides valuable information regarding the factors influencing operating time during retrograde intrarenal surgery for renal stone.

Do Hounsfield Units have any significance in predicting intra- and postoperative outcomes in retrograde intrarenal surgery using Holmium and Thulium fiber laser? Results from the FLEXible ureteroscopy Outcomes Registry (FLEXOR).

To evaluate outcomes of flexible ureteroscopy for renal stones by comparing hard versus soft stones based on their attenuation on computed tomography (Hounsfield Units-HU). Patients were divided into two groups according to the type of laser employed [Holmium:YAG (HL) or Thulium fiber laser (TFL)]. Residual fragments (RF) were defined as > 2mm. Multivariable logistic regression analysis was performed to evaluate factors associated with RF and RF needing further intervention. 4208 patients from 20 centers were included. In whole series, age, recurrent stones, stone size, lower pole stones (LPS), and multiple stones were predictors of RF at multivariable analysis and LPS and stone size with RF requiring further treatment. HU and TFL were associated with lesser RF and RF requiring an additional treatment. In HU < 1000 stones, recurrent stones, stone size, and LPS were predictors of RF at multivariable analysis, whereas TFL was less likely associated with RF. Recurrent stones, stone size, and multiple stones were predictors of RF requiring further treatment, while LPS and TFL were associated with lesser RF requiring further treatment. In HU ≥ 1000 stones, age, stone size, multiple stones, and LPS were predictors of RF at multivariable analysis, while TFL was less likely associated with RF. Stone size and LPS were predictors of RF requiring further treatment, whereas TFL was associated with RF requiring further treatment. Stone size, LPS, and use of HL are predictors of RF after RIRS for intrarenal stones regardless of stone density. HU should be considered an important parameter in predicting SFR.

Mini-Perc for Renal Stones-A Single Center Experience and Literature Review.

The aim of this study was to analyze the outcomes of miniaturized nephrolithotomy (mini-perc) in the management of renal stones with a diameter smaller than 20 mm. We retrospectively reviewed the records of 102 patients who underwent mini-perc between March 2015 and March 2020 in our department. The primary objective was the stone-free rate, but we also analyzed the retreatment rate, complications, hospital stay, operative time and reduction in hemoglobin level. All these patients had this technique as their first-line treatment, in a prone position, using a 16 Fr sheath size. Data were compared to a series of patients from the literature, treated with conventional PCNL. The patients had calculus limited to either a single calyx or just extending to the renal pelvis, and stone size was less than 20 mm in its maximal dimension. The intrarenal stone location was in the upper calyx in 7 cases, middle calyx in 20 cases and lower calyx in 46 cases, and there were 29 patients with renal pelvis stone. The male to female ratio was 1.5:1, and the median age was 48.4 years. The average stone size was 17.4 mm in diameter (ranging between 9 and 20 mm) and all cases underwent Ho-YaG laser lithotripsy, ballistic energy and combined ultrasonic and ballistic lithotripsy. At the end of the procedure, an antegrade double J stent was placed under fluoroscopy for a maximum of 2 weeks in 42 cases, while 9 cases needed a nephrostomy tube 12-14 F. A total of 51 cases were totally tubeless. Our median operative time was 61 min (ranging from 35 to 75 min). The median hospitalization stay was 3.8 days. The stone free rate was 90.1% after one procedure, only nine (8.8%) cases needed a "second look" flexible ureteroscopy, and the final stone-free rate was 98% (absence of detectable calculi on ultrasound, KUB or non-contrast CT scan). The overall complication rate was 6.86% (Clavien classification I-57.14%; II-28.5%; III-14.2%), while no Clavien IV or V complications were reported. No patient required a blood transfusion, and mean hemoglobin loss was 0.81 mg/dL. Overall, our results are better than similar data for conventional PCNL in the literature. The "mini-perc" technique is an effective procedure for the treatment of the renal lithiasis that is less or equal to 2 cm. The results demonstrated that this minimally invasive technique is associated with a higher stone-free rate and minimal complications.

Quality of life of patients treated for kidney stones 10–20 mm in diameter in terms of the type of operation performed: A qualitative study

Urolithiasis is a common chronic disease whose effect on patients' quality of life (QOL) is considerable but depends on the treatment received, differing between types of surgery. Intrarenal stones can be treated with different techniques: extracorporeal shock wave lithotripsy (ESWL), flexible ureteroscopy (fURS), and mini percutaneous nephrolithotomy (mini-PCNL), with proportional success and complication rates. The aim of this study was to qualitatively explore the impact of the different techniques on patients' QOL and understand their experiences of treatment choices. Patients treated for medium-sized kidney stones (10-20mm in diameter) were interviewed in a semi-structured manner. The interview data were transcribed and analyzed by theme according to consolidated criteria for reporting qualitative research (COREQ) guidelines. Data saturation was achieved after interviewing 15 patients. The mean interview time was 34min (standard deviation (SD), 6.8min). The mean patient age was 54 years (SD, 9.5 years). Eight patients underwent ESWL, 10 were treated with fURS, and 8 underwent mini-PCNL. Twenty-seven subthemes were coded and regrouped into eight major themes, namely: no sense of choice in the decision-making process for eleven patients; extremely negative experiences of double-J stents for fourteen patients; concern about the risk of recurrence or treatment failure for thirteen patients; complicated hygiene and dietary recommendations for nine patients; technique-dependent postoperative outcomes; relatively well-tolerated operations for thirteen patients; a poor experience of sick leave, often because of a double-J stent; different views regarding future operations. In fact, a third of patients would choose the most effective treatment, a third would choose the simplest procedure and the last third would trust their urologist. Patients' experiences of these operations are variable. Urologists must support their patients by presenting the different treatment options with clear, appropriate, and unbiased information. This should ensure patients take part in treatment decisions as part of a personalized treatment plan.

Role of Preoperative Ureteral Stent on Outcomes of Retrograde Intra-Renal Surgery (RIRS) in Children. Results From a Comparative, Large, Multicenter Series

To assess outcomes of pre-stenting versus non-pre-stenting in children undergoing retrograde intrarenal surgery (RIRS) for intrarenal stones. Children/adolescent with kidney stones undergoing RIRS in 9 centers between 2015 and 2020 were retrospectively reviewed. ureteral lithotripsy, bilateral procedures. Stone-free status was evaluated at 3-month and defined as a single residual fragment (RF) ≤2 mm/absence of multiple fragments. Patients were divided into two groups (Group 1 no-prestenting; Group 2 prestenting). Student's, Chi-square and Fisher's exact test was used to assess difference between groups. Univariable and multivariable logistic regression analysis were performed to predict RF. Statistical significance: P-value <0.05. Three hundred eighty-nine children/adolescents were included (192 patients in Group 1). Prestented patients were younger compared with non-prestented (mean age 8.30 ± 4.93 vs 10.43 ± 4.30 years, P < 0.001). There were no differences in stone characteristics (number, size, locations). Lasing and total surgical time were similar. Urinary tract infections were more prevalent in Group 2 (10.7%) compared to Group 1 (3.7%, P=0.016). Sepsis occurred in 2.1% of patients in Group 2 and no patient in Group 1 (P=0.146). 30.7% patients in Group 1 and 26.4% in Group 2 had RF (P=0.322). In univariate logistic regression analysis, stone size was associated with RF (OR 1.12 95%CI 1.06-1.18, P < 0.001), whereas Thulium fiber laser with a lower incidence (OR 0.24 95%CI 0.06-0.69, p=0.020). Multivariate logistic regression analysis showed that stone size was associated with RF (OR 1.20 95%CI 1.08-1.36, P=0.001). RIRS showed similar stone-free rate in pre and non-prestented children/adolescents, although prestented patients were younger. A higher risk of post-operative infections was reported in prestented patients.

Initial Experience of Totally Tubeless Ultra-Mini Percutaneous Nephrolithotomy

Objectives : The Objectives of this study is to determine the outcome and effectiveness of Ultra-mini percutaneous nephrolithotomy (PCNL) for treating low-volume renal stone without placement of any stent and nephrostomy tube as a supplement to the conventional PCNL. Material and methods: The Patients who underwent ultra-mini PCNL bwtween July 2018 to December 2018. were studied.This was a prospective study of 14 patients.This study was carried out in urology centre of CMH Dhaka.Before the study ethical clearance was taken from hospital ethical committee. All these patients had their first-line treatment. The patients had calculus limited to either a single calyx or just extending to the pelvis and the stone size was less than 1.5 cm in its maximal dimension. The mean stone size was 10.8+_4.2(5-15mm). An 6 Fr operating nephroscope was used. The patients were placed in prone position. The stones were fragmented using Holmium-YAG laser. Various surgical outcomes including duration of the surgery, stone-free rate and any subsequent complications-if any-were analyzed.The stone free rate was assessed on the 1st day and at three month after surgery by X-ray KUB and ultrasonography. Results: The study includes a series of 14 patients (one patient treated with bilateral renal stone disease). The mean age of the patients was 39.07 years and body mass index was 25.5 kg/m2. Intrarenal stone location was as follows: lower calyx, n=7; middle calyx, n=3, upper calyx, n=1, and pelvis, n=3. Median operative time was 52.66 min (range: 40–65) and the stone-free rate was 93.3% at first day and 97% after three month follow up.. Only one patient had residual fragments and needed subsequent extracorporeal shock wave lithotripsy. Conclusion: Ultra-mini PCNL in prone position with a complete tubeless approach for renal stone disease is a safe method for treating low-volume stone disease. A long term large scale multicentre study may be required to validate this technique. Bangladesh J. Urol. 2021; 24(2): 118-123

Surgical Parameters Related to Excessive Intrarenal Pressure during Minimally Invasive Percutaneous Nephrolithotomy in the Supine Position: A Prospective Observational Clinical Study.

Objective Excessive intrarenal pressure (IRP) during surgery for renal stones is related to postoperative complications due to systemic absorption of bacteria and endotoxins. This study is aimed at evaluating factors that induce excessive IRP in minimally invasive percutaneous lithotripsy (mini-PCNL) in the supine position. Methods 27 patients underwent mini-PCNL for intrarenal stones under supine position and were analyzed in this study. The IRP changes were measured at the phases of “baseline,” “table tilting,” “upper-pole navigation,” “stone fragmentation,” and “vacuum cleaning effect.” The relationship between the mean IRP and cumulative time of IRP ≥ 30 cmH2O was analyzed by according to the surgical parameters. Multiple regression analysis showed the effect of the surgical parameters on postoperative fever-related IRP elevation. Results Mean age was 59.3 ± 14.6 years. The mean stone burden was 24.6 ± 8.1 mm3. IRP was higher than baseline (31.6 ± 12.1) during upper-pole navigation (60.0 ± 22.9, p = 0.003) and stone fragmentation (46.2 ± 9.9, p < 0.001). The subgroup's IRP baseline < 20 cmH2O significantly increased during the upper-pole navigation. Changes in IRP at each stage were affected by baseline IRP (p < 0.001), operation methods (p = 0.021), number of calyces with stones (p = 0.034), and laser energy of Joules (p = 0.041) and frequency (p = 0.038). Conclusion In supine mini-PCNL, the IRP was higher during laser fragmentation and upper-pole navigation. The table tilting procedure can be helpful in selected patients. The vacuum cleaner effect did not affect IRP.