Lower Pole Stones Research Articles

External validation of the R.I.R.S. scoring system to predict stone-free rate after retrograde intrarenal surgery

BackgroundThe R.I.R.S. scoring system is defined as a novel and straightforward scoring system that uses the main parameters (kidney stone density, inferior pole stones, stone burden, and renal infundibular length) to identify most appropriate patients for retrograde intrarenal surgery (RIRS). We strived to evaluate the accuracy of the R.I.R.S. scoring system in predicting the stone-free rate (SFR) after RIRS.MethodsIn our medical center, we retrospectively analyzed charts of patients who had, between September 2018 and December 2019, been treated by RIRS for kidney stones. A total of 147 patients were enrolled in the study. Parameters were measured for each of the four specified variables.ResultsStone-free status was achieved in 105 patients (71.43%), and 42 patients had one or more residual fragments (28.57%). Differences in stone characteristics, including renal infundibulopelvic angle, renal infundibular length, lower pole stone, kidney stone density, and stone burden were statistically significant in patients whether RIRS achieved stone-free status or not (P < 0.001, P: 0.005, P < 0.001, P < 0.001, P: 0.003, respectively). R.I.R.S. scores were significantly lower in patients treated successfully with RIRS than patients in which RIRS failed (P < 0.001). Binary logistic regression analyses revealed that R.I.R.S. scores were independent factors affecting RIRS success (P = 0.033). The area under the curve of the R.I.R.S. scoring system was 0.737.ConclusionsOur study retrospectively validates that the R.I.R.S. scoring system is associated with SFR after RIRS in the treatment of renal stones, and can predict accurately.

Comparison of Mini Percutaneous Nephrolithotomy (Mini PCNL) and Retrograde Intrarenal Surgery (RIRS) for the Minimal Invasive Management of Lower Caliceal Stones.

To evaluate the stone-free rates, quality of life, complications, use of fluoroscopy, analgesic requirements, a hospital stay following the management of lower calyceal with two different techniques (Mini Percutaneous Nephrolithotomy and Retrograde Intrarenal Surgery) in a prospective manner. 50 patients with a diagnosis lower pole 1-2 cm stone were included into the study and were randomized into two groups.(Mini PCNL n: 25) ( RIRS n: 25). Safety and efficacy of both methods along with some other certain related factors were comparatively evaluated in both groups. There was no significant difference between preoperative stone size, stone to skin distance, hemogram and creatinine values, need for analgesic drug, patients' replies to visual analog scale (VAS). The duration of both the hospital stay and the exposure to fluoroscopy, hematocrit decrease due to hemorrhage, complication rates were significantly higher in cases undergoing mini PCNL when compared to RIRS. Additionally, any significant difference was not observed with respect to the stone-free rates. Despite an increase in quality of life following the both type operations was noted; there was no significant difference in the quality of life between the patients in both groups. Our findings demonstrated that both surgical techniques are the feasible alternatives in the minimal invasive treatment of lower pole stones. Although there was no meaningful difference in stone-free rates between two groups; complications, use of fluoroscopy, bleeding and duration of hospital stay were noted to be significantly higher in cases treated with mini PCNL.

Ретроградная гибкая уретероскопия с тулиевой волоконной нефролитотрипсией в лечении пациентов с камнем нижней полярной чашечки

Introduction The SuperPulse Thulium (Tm) fiber laser (wavelength of 1.94 m) has been recently introduced as a directed-energy source for urology. Preclinical studies have shown a significant potential of the SuperPulse Tm fiber laser (SP TFL) for lithotripsy. However, clinical reports of using SP TFL to treat urolithiasis are still few and limited. Of special interest are challenging cases, e.g., lower pole stones, when extreme deflection of the instrument is required. Objective To evaluate the effectiveness of the SuperPulse Tm fiber laser in the management of lower pole small calyceal stones during flexible ureteroscopy (F-URS). Method s. The SuperPulse Tm fiber laser device (Urolase 2, IRE Polus, Fryazino, Russia) has been cleared for clinical use by the Ministry of Health of Russian Federation. Study protocol has been approved by the Ethical Review Committee. Between January 2018 and February 2019, 130 patients with kidney stones have undergone Thulium fiber laser lithotripsy during F-URS. We retrospectively analyzed 15 of this patients with a single radiopaque lower pole calculus that were included in the present study. Stone size, stone density, lithotripsy time (from the first to last footswitch press) and lasering (laser emission) time were measured. The SP TFL was used for stone disintegration with different settings in dusting and fragmentation modes (0.1 - 4J, 7-300Hz, 6-40W) via a fiber with a 200-m core diameter. Low dose CT scanning was performed on POD 90 to assess SFR. Results Stone size ranged from 4 to 17 mm and stone density varied from 350 to 1459 HU. The average lithotripsy time was 12 min (3-30 min). The average lasering time was 1.3 min (0.4-2.5 min) and the mean hospital stay was 1.1+/-0.3 days. In all cases we reached the lower pole stone containing calyx with a laser fiber. The complication rates were evaluated by using the Clavien-Dindo grading system and did not exceed GII (6.6%). SFR on POD 90 was achieved in 86.6% of cases. Conclusions F-URS with SuperPulse Tm fiber laser is safe and effective option in the management of lower pole small calyceal stones. The possibility of using small laser fibers gives better instrument deflection which make possible to reach lower pole calyceal stones even with acute lower pole infundibulopelvic angle (IPA).

The clinical and cost effectiveness of surgical interventions for stones in the lower pole of the kidney: the percutaneous nephrolithotomy, flexible ureterorenoscopy and extracorporeal shockwave lithotripsy for lower pole kidney stones randomised controlled trial (PUrE RCT) protocol

IntroductionRenal stones are common, with a lifetime prevalence of 10% in adults. Global incidence is increasing due to increases in obesity and diabetes, with these patient populations being more likely to suffer renal stone disease. Flank pain from stones (renal colic) is the most common cause of emergency admission to UK urology departments. Stones most commonly develop in the lower pole of the kidney (in ~35% of cases) and here are least likely to pass without intervention. Currently there are three technologies available within the UK National Health Service to remove lower pole kidney stones: extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and flexible ureterorenoscopy (FURS) with laser lithotripsy. Current evidence indicates there is uncertainty regarding the management of lower pole stones, and each treatment has advantages and disadvantages. The aim of this trial is to determine the clinical and cost effectiveness of FURS compared with ESWL or PCNL in the treatment of lower pole kidney stones.MethodsThe PUrE (PCNL, FURS and ESWL for lower pole kidney stones) trial is a multi-centre, randomised controlled trial (RCT) evaluating FURS versus ESWL or PCNL for lower pole kidney stones. Patients aged ≥16 years with a stone(s) in the lower pole of either kidney confirmed by non-contrast computed tomography of the kidney, ureter and bladder (CTKUB) and requiring treatment for a stone ≤10 mm will be randomised to receive FURS or ESWL (RCT1), and those requiring treatment for a stone >10 mm to ≤25 mm will be randomised to receive FURS or PCNL (RCT2). Participants will undergo follow-up by questionnaires every week up to 12 weeks post-intervention and at 12 months post-randomisation. The primary clinical outcome is health status measured by the area under the curve calculated from multiple measurements of the EuroQol five dimensions five-level version (EQ-5D-5L) questionnaire up to 12 weeks post-intervention. The primary economic outcome is the incremental cost per quality-adjusted life year gained at 12 months post-randomisation.DiscussionThe PUrE trial aims to provide robust evidence on health status, quality of life, clinical outcomes and resource use to directly inform choice and National Health Service provision of the three treatment options.Trial registrationISRCTN: ISRCTN98970319. Registered on 11 November 2015.

MP27-05 COMPARATIVE COST-EFFECTIVENESS OF PERCUTANEOUS NEPHROLITHOTOMY, URETEROSCOPY, AND EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR THE MANAGEMENT OF 1-2CM RENAL STONES

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost and Outcomes Measures (MP27)1 Apr 2020MP27-05 COMPARATIVE COST-EFFECTIVENESS OF PERCUTANEOUS NEPHROLITHOTOMY, URETEROSCOPY, AND EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR THE MANAGEMENT OF 1-2CM RENAL STONES Kevin Wymer*, Tristan Juvet, Vidit Sharma, Aaron Potretzke, Deepak Agarwal, Marcelino Rivera, and Matthew Gettman Kevin Wymer*Kevin Wymer* More articles by this author , Tristan JuvetTristan Juvet More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Aaron PotretzkeAaron Potretzke More articles by this author , Deepak AgarwalDeepak Agarwal More articles by this author , Marcelino RiveraMarcelino Rivera More articles by this author , and Matthew GettmanMatthew Gettman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000866.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Guidelines for the treatment of renal stones 1-2cm in size include ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and extracorporeal shock wave lithotripsy (ESWL). A recent meta-analysis comparing these treatments found the highest stone-free rate with PCNL, followed by URS and ESWL; however, complication rates were highest for PCNL. A cost-effectiveness evaluation comparing these three modalities has not yet been performed. METHODS: A Markov decision analytic model was created to compare cost-effectiveness of PCNL, URS, and ESWL for 1-2cm renal stones based on stone free and complication rates from a meta-analysis. Costs were based on 2018 Medicare rates. Quality adjusted life years (QALYs) were assigned from the literature. The incremental cost-effectiveness ratio (ICER) between strategies was compared, using a willingness-to-pay (WTP) threshold of $100,000/QALY. Univariate and multivariable Monte Carlo sensitivity analyses were performed. A subset analysis was performed for 1-2cm lower pole stones. RESULTS: At 3 years follow up, mean costs per patient were $10,079 (PCNL), $5,779 (URS), and $4,804 (ESWL). PCNL resulted in the highest QALYs at 2.97 compared to 2.96 and 2.95 for URS and ESWL, respectively. On aggregate, PCNL was not cost-effective relative to ESWL ($302,751/QALY) or URS ($1,466,110/QALY), whereas URS was more cost-effective than ESWL (ICER=$67,257/QALY). The model was sensitive to the stone free rate of ESWL and URS as well as the cost of PCNL, URS, and ESWL. ESWL became most cost-effective with a stone free rate ≥69% or URS stone free rate ≤82%. PCNL became most cost-effective when cost ≤$5,205. On multivariable sensitivity analysis, the most cost-effective strategy was URS in 67%, ESWL in 32.5%, and PCNL in 0.5% of simulations. When evaluating lower pole stones alone, the most cost-effective strategy was URS in 84%, ESWL in 8%, and PCNL in 8% of microsimulations (Figure). CONCLUSIONS: For 1-2 cm stones, URS is most likely to be cost-effective on a population level based on data from meta-analyses. However, for lower pole stones, particularly with a higher willingness to pay threshold, PCNL becomes increasingly favorable. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e411-e411 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Wymer* More articles by this author Tristan Juvet More articles by this author Vidit Sharma More articles by this author Aaron Potretzke More articles by this author Deepak Agarwal More articles by this author Marcelino Rivera More articles by this author Matthew Gettman More articles by this author Expand All Advertisement PDF downloadLoading ...

PD34-06 FLEXIBLE URETEROSCOPY FOR LOWER POLE RENAL STONES: NOVEL SUPERPULSE THULIUM (TM) FIBER LASER LITHOTRIPSY. FIRST CLINICAL RESULTS

You have accessJournal of UrologyStone Disease: Surgical Therapy V (PD34)1 Apr 2020PD34-06 FLEXIBLE URETEROSCOPY FOR LOWER POLE RENAL STONES: NOVEL SUPERPULSE THULIUM (TM) FIBER LASER LITHOTRIPSY. FIRST CLINICAL RESULTS Dmitry Korolev*, Roman Klimov, Dmitry Tsarichenko, Mikhail Enikeev, Alim Dymov, Stanislav Ali, Gagik Akopyan, Vladimir Lekarev, Mark Taratkin, Leonid Rapoport, Dmitry Enikeev, and Peter Glybochko Dmitry Korolev*Dmitry Korolev* More articles by this author , Roman KlimovRoman Klimov More articles by this author , Dmitry TsarichenkoDmitry Tsarichenko More articles by this author , Mikhail EnikeevMikhail Enikeev More articles by this author , Alim DymovAlim Dymov More articles by this author , Stanislav AliStanislav Ali More articles by this author , Gagik AkopyanGagik Akopyan More articles by this author , Vladimir LekarevVladimir Lekarev More articles by this author , Mark TaratkinMark Taratkin More articles by this author , Leonid RapoportLeonid Rapoport More articles by this author , Dmitry EnikeevDmitry Enikeev More articles by this author , and Peter GlybochkoPeter Glybochko More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000905.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The SuperPulse Thulium (Tm) fiber laser (wavelength of 1.94 µm) has been recently introduced as a directed-energy source for urology. Preclinical studies have shown a significant potential of the SuperPulse Tm fiber laser (SP TFL) for lithotripsy. However, clinical reports of using SP TFL to treat urolithiasis are still few and limited. Of special interest are challenging cases, e.g., lower pole stones, when extreme deflection of the instrument is required. To evaluate the effectiveness of the SuperPulse Tm fiber laser in the management of lower pole small calyceal stones during flexible ureteroscopy (F-URS). METHODS: The SuperPulse Tm fiber laser device (Urolase 2, IRE Polus, Fryazino, Russia) has been cleared for clinical use by the Ministry of Health of Russian Federation. Study protocol has been approved by the Ethical Review Committee. Between January2018 and February 2019, 130 patients with kidney stones have undergone Thulium fiber laser lithotripsy during F-URS. We retrospectively analyzed 15 of this patients with a single radiopaque lower pole calculus that were included in the present study. Stone size, stone density, lithotripsy time (from the first to last footswitch press) and “lasering” (laser emission) time were measured. The SP TFL was used for stone disintegration with different settings in dusting and fragmentation modes (0.1 – 4J, 7-300Hz, 6-40W) via a fiber with a 200-μm core diameter. Low dose CT scanning was performed on POD 90 to assess SFR. RESULTS: Stone size ranged from 4 to 17 mm and stone density varied from 350 to 1459 HU. The average lithotripsy timewas 12 min (3-30 min). The average “lasering” time was 1.3 min (0.4-2.5 min) and the mean hospital stay was 1.1 ± 0.3 days. In all cases we reached the lower pole stone containing calyx with a laser fiber. The complication rates were evaluated by using the Clavien-Dindo grading system and did not exceed GII. The overall postoperative complication rate was 26.6% (GI 20%; GII 6.6%). SFR on POD 90 was achieved in 86.6% of cases. CONCLUSIONS: F-URS with SuperPulse Tm fiber laser is safe and effective option in the management of lower pole small calyceal stones. The possibility of using small laser fibers gives better instrument deflection which make possible to reach lower pole calyceal stones even with acute lower pole infundibulopelvic angle (IPA). Source of Funding: non © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e713-e713 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dmitry Korolev* More articles by this author Roman Klimov More articles by this author Dmitry Tsarichenko More articles by this author Mikhail Enikeev More articles by this author Alim Dymov More articles by this author Stanislav Ali More articles by this author Gagik Akopyan More articles by this author Vladimir Lekarev More articles by this author Mark Taratkin More articles by this author Leonid Rapoport More articles by this author Dmitry Enikeev More articles by this author Peter Glybochko More articles by this author Expand All Advertisement PDF downloadLoading ...

MP15-09 DISPLACING STONES FROM THE LOWER POLE DURING RETROGRADE INTRARENAL SURGERY (RIRS): IMPROVED STONE FREE RATES OR A WASTE OF TIME? A PROSPECTIVE RANDOMIZED STUDY

You have accessJournal of UrologyStone Disease: Surgical Therapy III (MP15)1 Apr 2020MP15-09 DISPLACING STONES FROM THE LOWER POLE DURING RETROGRADE INTRARENAL SURGERY (RIRS): IMPROVED STONE FREE RATES OR A WASTE OF TIME? A PROSPECTIVE RANDOMIZED STUDY Blair Gallante*, Jacob N. Bamberger, William Atallah, Anna Zampini, and Mantu Gupta Blair Gallante*Blair Gallante* More articles by this author , Jacob N. BambergerJacob N. Bamberger More articles by this author , William AtallahWilliam Atallah More articles by this author , Anna ZampiniAnna Zampini More articles by this author , and Mantu GuptaMantu Gupta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000840.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal stones located in the lower pole (LP) are more difficult to access, fragment, and are more likely to cause ureteroscope damage and result in residual fragments (RF). To improve the stone free rate and decrease damage to the ureteroscope, some urologists will displace a LP stone to a more accessible part of the kidney. Although some have advocated using this technique, its benefit has not been definitively demonstrated on stone clearance and other treatment parameters. Retrospective work has shown that a higher stone free rate can be obtained by using this technique when treating lower pole calculi 1 to 2cm. We sought to prospectively compare the effect of stone fragmentation in situ versus fragmentation after displacing the stone on stone clearance in patients with LP stones. Our primary outcome was stone free rates. METHODS: In this prospective, randomized study, patients were included if they had stones only in the LP, total stone burden was 7-15 mm, and did not have anatomic kidney abnormalities, pre-existing ureteral stents, or ureteral stones. Patients were randomized into the in situ or displacement group prior to URS. Demographics, comorbidities, and operative parameters were documented. We determined stone free rates using renal ultrasound and abdominal x-ray (KUB) at 1-month follow-up. Mann-Whitney U and Chi-Square tests were conducted to assess differences between the groups. RESULTS: Our data includes 68 patients. 29 in situ patients and 39 displaced patients have completed the study with imaging. Displaced stone patients had higher stone free rates when compared to in situ patients (97% vs. 83%, p=.035). In addition, both total surgery time and total laser energy were higher in the displaced group (p=.005 and p=.049). CONCLUSIONS: Displacing LP stones may require more OR time, but does improve stone free rates when compared to patients who are treated in situ. Increased OR time and laser energy may be due to the time it takes to displace the stone and time spent to achieve complete stone fragmentation and removal. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e207-e208 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Blair Gallante* More articles by this author Jacob N. Bamberger More articles by this author William Atallah More articles by this author Anna Zampini More articles by this author Mantu Gupta More articles by this author Expand All Advertisement PDF downloadLoading ...

Economic Considerations in the Management of Nephrolithiasis.

From health systems to individuals, nephrolithiasis is economically burdensome. The aim of the current paper is to characterize the financial burden of disease associated with nephrolithiasis with an emphasis on investigating treatment modality economic efficiency. For small volume practices and cases where there is high risk of scope damage, disposable flexible ureteroscope utilization seems to provide economic efficiency. The rise in global prevalence of stone disease is a large contributing factor to increasing costs associated with nephrolithiasis. A large proportion of costs from kidney stones stem from ED visits and inpatient care. There are opportunities to save money by transitioning care to outpatient settings in scenarios that allow such transition. Metaphylaxis and prevention strategies are effective at lowering costs in properly selected patient populations. Flexible ureteroscopy and percutaneous nephrolithotomy (PCNL) are the most economically efficient methods of surgically treating stone disease, with PCNL being reserved for large and lower pole stones. Time off work and other indirect costs, while challenging to quantify, are important considerations in the economics of nephrolithiasis.

Influence of Lower Pole Infundibulopelvic Angle on Success of Retrograde Flexible Ureteroscopy and Laser Lithotripsy for the Treatment of Renal Stones.

Objectives: Influence of renal anatomy on success rates for shockwave lithotripsy has been reported in the literature with emphasis on lower pole anatomy. Influence of renal anatomy has not been evaluated in the setting of ureteroscopy and laser lithotripsy for stone treatment. This study analyzed the influence of infundibulopelvic angle (IPA) of the lower pole on the outcomes of ureteroscopy and laser lithotripsy with respect to stone-free rate and surgical recurrence. Materials and Methods: We retrospectively analyzed 735 renal units undergoing retrograde flexible ureteroscopy (fURS) with laser lithotripsy between January 2009 and December 2016. All cases were performed at a single institution. No exclusion criterion was applied with regard to preoperative stone location. Success was defined as no evidence of residual stone fragments on kidney, ureter, and bladder radiograph within 2 months of surgery. Failure was defined as any stone present on imaging. Lower pole IPA was measured on intraoperative retrograde pyelogram as described by Elbahanasy et al. Univariate and multivariate analyses of factors contributing to stone-free rate were performed. Secondary outcomes included surgical recurrence-free survival. Results: Of the 735 cases evaluated, 243 cases had a retrograde pyelogram stored in our Picture Archiving and Communication System (PACS) sufficient for IPA interpretation. Of these patients, 122 (50%) were women. In total, 127 patients (52.3%) were stone free on follow-up imaging, whereas 116 (47.7%) had residual stone burden. In total, 144 (59%) patients had ≤3 mm stone burden on follow-up imaging. In multivariate analysis, residual stone fragments were significantly associated with acute IPA <90° (<0.001), lower pole stones preoperatively (<0.001), and larger stone size (0.001). IPA <90° and larger stone size were both found to be statistically significantly associated with need for repeat surgery. Conclusions: Our data show that more acute IPA and larger preoperative stone size negatively affect stone-free rate and need for repeat surgery after retrograde fURS with laser lithotripsy for treatment of renal stones.

Systematic Review and Meta-Analysis Comparing Percutaneous Nephrolithotomy, Retrograde Intrarenal Surgery and Shock Wave Lithotripsy for Lower Pole Renal Stones Less Than 2 cm in Maximum Diameter.

The aim of the current systematic review and meta-analysis is to provide an answer on which is the most appropriate approach for the management of the lower pole stones with a maximal dimension of 2 cm or less. A systematic review was conducted on PubMed®, SCOPUS®, Cochrane and EMBASE®. The PRISMA guidelines and the recommendations of the EAU Guidelines office were followed. Retrograde intrarenal surgery, shock wave lithotripsy and percutaneous nephrolithotomy were considered for comparison. The primary end point was the stone-free rate. A total of 15 randomized controlled trials were eligible. Percutaneous nephrolithotripsy and retrograde intrarenal surgery have higher stone-free rates in comparison to shock wave lithotripsy and require fewer re-treatment sessions. Operative time and complications seem to favor shock wave lithotripsy in comparison to percutaneous nephrolithotripsy, but this takes place at the expense of multiple shock wave lithotripsy sessions. Retrograde intrarenal surgery seems to be the most efficient approach for the management of stones up to 1 cm in the lower pole. The pooled analysis of the eligible studies showed that the management of lower pole stones should probably be percutaneous nephrolithotripsy or retrograde intrarenal surgery to achieve stone-free status over a short period and minimal number of sessions. For stones smaller than 10 mm, retrograde intrarenal surgery is more efficient in comparison to shock wave lithotripsy. The decision between the 2 approaches (percutaneous nephrolithotripsy or retrograde intrarenal surgery) should be individual, based on the anatomical parameters, the comorbidity and the preferences of each patient.

Flexible Ureterorenoscopy Versus Extracorporeal Shock Wave Lithotripsy for Treatment of Lower Pole Renal Stones

Background: Urolithiasis affects 5-15% of the world population, with high recurrence, (2) which at 5 years can be up to 50%, with high frequency in the labor force population, which produces a high individual and hospital cost, so it constitutes a health problem of high socio-sanitary interes. Objective: To compare the treatment outcomes of Flexible ureterorenoscopy and extracorporeal shock wave lithotripsy for patients with lower pole stones. Patients and method: Data base review for the patients in the period from first of Jan 2018 to the end of June 2019, in which 131 patients underwent interventions for the management of small lower pole stone. Sixty-seven patients were treated by ESWL and the rest (64) treated by F-URS. The most common complication was UTI 9/19 Results: 86/131 were male and 45/131 were female with mean age for F-URS group (52±9.7 years) and (49.6±12.3 years) for ESWL group, with highly significant differences regarding the stone size between the studied groups. The treatment rate, operative time and procedure per patient were highly significantly decrease in F-URS group than in ESWL (p<0.001). Moreover, significant association were notice between the studied groups among SFR at 3 months and secondary procedures. Conclusion: lower pole renal stone in size between 10-20 mm treated successfully and more efficiently by F-URS in comparison with ESWL.

Efficacy and safety of fURS in stones larger than 20 mm: is it still the threshold?

IntroductionThe aim of this article was to evaluate the safety and efficiency of flexible ureteroscopy (fURS) in the management of renal calculi larger than 20 mm.Material and methodsA total of 92 cases with renal calculi were managed with fURS and divided into two groups depending on the size of the stones; <20 mm and >20 mm (Group 1 and Group 2, respectively). The groups were compared with respect to treatment-related parameters including success, complication rates, hospitalization period and need for auxiliary procedures with an emphasis on the rate of infections. Success rates were also compared in each group according to stone location.ResultsOverall success rates after 3 months showed that stone-free rates in both groups were 84.1% (< 20 mm) and 58.33% (>20 mm) respectively (p = 0.008). The success rates of upper/mid pole (100% vs. 80%) and pelvis stones (83.3% vs. 75%) showed no statistically significant difference (p = 0.5, p = 0.51 respectively). Success rates for stones located in the lower pole were 75% vs. 14.28% respectively (p = 0.008). The rate of infectious complications was significantly higher in cases undergoing fURS for relatively larger stones (22.9%) as compared to smaller calculi (6.8%) (p = 0.032). No complications were recorded in Group 1, while 2 cases in Group 2 (4.1%) developed ureteral stricture.ConclusionsDespite the relatively low stone-free rates in lower pole stones, our current results indicate that fURS can be an effective and safe treatment alternative to PNL in larger renal stones (>20 mm) located in the pelvis and in the upper part of the calyceal system of the involved kidney.

Prospective Randomized Study of Fixed Laser Setting Verses Variable Laser Settings for a Better Stone Free Rate

OBJECTIVE: To assess the outcome of variable laser settings verses fixed setting on the stone free rate and complications. MATERIAL AND METHOD: We conducted a prospective, single-blind randomized controlled study. Solitary renal non lower pole stones 10 to 20 cm were included. A total of 113 Patients were randomly divided in to two groups. In group A, fixed laser setting was used at 1.0J energy and 12Hz frequency during the entire procedure. In Group B, variable laser settings were used; initial fine fragmentation was performed @ 1.0J X 12Hz. Once the residual stone reduced enough to wobble, the energy was reduced to 0.8 J and 8Hz. Settings were further reduced to 0.5J and 5Hz as required to complete the fragmentation process with minimal migration. RESULT: Group A had 58 patients and Group B 55 patients for analysis of perioperative variables. Stone free rate (<2mm) is in favor of systematic stone dusting with variable frequency (95.8% vs 83.6%, p=0.05). Post-operative fever and pain were not statistically significant between the groups (fever 10.3% vs 9.1%, p=1.00) (pain mean VAS 1/10 in group A vs 2/10 in group B). CONCLUSION: The solitary hard stones of 10 to 20 mm can be treated with more than 95% SFR using variable laser settings producing fine dust, without increase in significant postoperative complications or hospital stay.

Treatment of Lower Pole Renal Stones-Extracorporeal Shock Wave Lithotripsy vs Endourology. A literature review

Urolithiasis is a subject of great interest in the urological world nowadays, due to the increasing incidence of the disease caused by the metabolic disorders that arise from the modern lifestyle, which is often not beneficial to the human body. Also, pathology is intensely debated because its treatment involves significant costs for society. The present article aims to compare the endourological treatment methods with extracorporeal shock waves lithotripsy for lower calyceal lithiasis, which is an intensely debated topic, and the opinions are divided regarding the choice of the optimal method for the management of this pathology. The location of the stone at the level of the inferior calyceal group implies a difficult approach regardless of the chosen treatment method, but also a poor excretion of the remaining fragments, frequently encountering a lower stone-free rate. Thus, the treatment methods were compared, taking into account the anatomic factors, the size of the stone, its hardness, the risk of the occurrence of intraoperative or postoperative complications, the necessity of a possible reintervention and the duration of the intervention. Last but not least, the patient’s preference must be taken into account, obviously, after a physician-patient dialogue explaining to the patient the individual treatment, and being guided to the optimal therapy for the patient. Keywords: urinary lithiasis, lower pole stones, extracorporeal shockwave lithotripsy, flexible ureterorenoscopy, percutaneous nephrolithotomy

Spoilt for Choice: A Survey of Current Practices of Surgical Urinary Stone Treatment and Adherence to Evidence-Based Guidelines among Swiss Urologists

Introduction: Urologists have to master a variety of techniques to be able to offer the most appropriate surgical stone treatment for each individual patient. Therefore, we performed a survey among board-certified Swiss urologists to assess the availability of the different surgical methods, the current practices of surgical treatment of urolithiasis and the adherence to evidence-based guideline recommendations in Switzerland. Methods: A 14-question survey assessed the working environment, equipment, perioperative settings and decision trees for specific stone scenarios. Data was analyzed using descriptive statistics and chi-square tests to determine differences between frequencies of answers. Results: Hundred and five members of Swiss Urology (38%) completed the survey. All treatment modalities are available for the majority of respondents. Ureterorenoscopy was found to have the highest availability (100%) and was the preferred choice in the majority of stone scenarios. A high adherence to the guidelines was found for the treatment of ureteral stones <10 mm (100% proximal and distal), and >10 mm (69% proximal, 94% distal). All respondents answered in accordance with the guidelines regarding the treatment of middle and upper pole stones <10 mm, 10–20 mm and lower pole stones 10–20 mm. Guideline adherence was 99% for lower pole stones <10 mm, 78% for lower pole stones >20 mm, and 63% for middle/upper pole stones >20 mm. Conclusion: This survey provides a detailed insight into current stone treatment practices in Switzerland. The full spectrum of urinary stone treatment options is available for the majority of Swiss urologists. The choice of treatment shows a high accordance with evidence-based guidelines and a preference for retrograde endoscopic surgery in the majority of stone scenarios.

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

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.

Are Stone Density and Location Useful Parameters That Can Determine the Endourological Surgical Technique for Kidney Stones That are Smaller than 2 cm? A Prospective Randomized Controlled Trial.

The patients who had kidney stones smaller than two cm and were planned to undergo surgery were randomly distributed into 2 groups prospectively. RIRS was performed in the RIRS group using a 7.5-F fiberoptic flexible ureterorenoscope while mini-PNL group was dilated up to 16.5F and mini-PNL was per-formed with 12F nephroscopy. Preoperative characteristics, operative and postoperative results were compared in two groups. Thereafter, intra and intergroup comparisons were made to determine the effects of Hounsfield unit (HU) value indicating the stone density being higher or lower than 677 and stone location on stone-free rates. The study involved 60 patients including 30 in each group. The groups' preoperative values were similar. The hospitalization time and the total duration of scopy were longer in mini-PNL when the postoperative values were compared (P < .0001). In terms of stone densities, HU values that were lower than 677 in the mini-PNL group affected the stone-free rate and reduced it from 100% (> 677HU) to 55.6% (< 677HU), whereas the change was significant (P = .005). Lower calyx stones affected the RIRS results negatively, whereas multiple calyceal stones affected the mini-PNL group negatively. Both methods had a similar success rate, but lower pole stones, multiple calyceal stones and stone density parameters affected the stone-free rates significantly, and these may be effective in treatment selection.

284 - Shockwave lithotripsy and ureteroscopy for the treatment of lower pole stones: Results from a statewide clinical registry

284 - Shockwave lithotripsy and ureteroscopy for the treatment of lower pole stones: Results from a statewide clinical registry

PT270 - Evaluation of the surgical outcome SWL, mini-PCNL and RIRS for the management of lower pole stones with a size

PT270 - Evaluation of the surgical outcome SWL, mini-PCNL and RIRS for the management of lower pole stones with a size <2cm stones: A systematic review and meta-analysis

Comparison of stone-free rates following shock wave lithotripsy, percutaneous nephrolithotomy, and retrograde intrarenal surgery for treatment of renal stones: A systematic review and network meta-analysis.

ObjectivesTo perform a systematic review and network meta-analysis comparing stone-free rates following retrograde intrarenal surgery (RIRS), extracorporeal shock wave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) treatments of renal stones.Materials and methodsClinical trials comparing RIRS, SWL, and PCNL for treatment of renal stones were identified from electronic databases. Stone-free rates for the procedures were compared by qualitative and quantitative syntheses (meta-analyses). Outcome variables are shown as risk ratios (ORs) with 95% credible intervals (CIs).ResultsA total of 35 studies were included in this network meta-analysis of success and stone-free rates following three different treatments of renal stones. Six studies compared PCNL versus SWL, ten studies compared PCNL versus RIRS, fourteen studies compared RIRS versus SWL, and five studies compared PCNL, SWL, and RIRS. The quality scores within subscales were relatively low-risk. Network meta-analyses indicated that stone-free rates of RIRS (OR 0.38; 95% CI 0.22–0.64) and SWL (OR 0.12; 95% CI 0.067–0.19) were lower than that of PCNL. In addition, stone-free rate of SWL was lower than that of RIRS (OR 0.31; 95% CI 0.20–0.47). Stone free rate of PCNL was also superior to RIRS in subgroup analyses including ≥ 2 cm stone (OR 4.680; 95% CI 2.873–8.106), lower pole stone (OR 1.984; 95% CI 1.043–2.849), and randomized studies (OR 2.219; 95% CI 1.348–4.009). In rank-probability test, PCNL was ranked as No. 1 and SWL was ranked as No. 3.ConclusionsPCNL showed the highest success and stone-free rate in the surgical treatment of renal stones. In contrast, SWL had the lowest success and stone-free rate.