Renal Stone Burden Research Articles

Efficacy Of Retrograde Intra-Renal Surgery For The Treatment Of Large Renal Stone Burdens: A SingleCenter Experience

Background: Retrograde intra-renal surgery (RIRS) has gained popularity as a result of technological advances. Although widely used, the literature on its feasibility for the treatment of large renal stone burdens is limited. This study aimed to assess the efficacy of RIRS for the treatment of large renal stone burdens.. Materials and Methods: Fifty-five patients with stone burdens ≥21 mm and treated with RIRS between November 2019 and October 2021 were evaluated for patient demographics, stone characteristics, and stonefree rates (SFR). Patients were divided into three groups according to stone burdens (21–30 mm, 31–40 mm, and >40 mm). A standard protocol for surgery and chemoprophylaxis was followed. The SFR was determined if there were no residual stones or fragments on follow-up images. All these patients were followed up on for a minimum of 3 months. Results: The mean age of patients was 54.11 ± 11.75 years. The mean stone burden and mean stone density were 32.36 ± 10.20 mm and 966 ± 337 HU, respectively. The mean cumulative endoscopy time was 142.0 ± 74.7 minutes per case. Endoscopy time was longer for stone densities >1000 HU. The overall SFR was 78.2%, with an average of 1.58 sessions of RIRS. SFRs for 21–30 mm, 31–40 mm, and >40 mm groups were 92.9%, 68.8%, and 54.5%, respectively. Conclusion: RIRS is an effective therapeutic option for treating stone burdens of 21–30 mm with overall SFR of 92.9%. When the stone burden exceeds 30 mm, RIRS should only be offered to individuals who are not candidates for other therapeutic options. To better counsel the patient for a staged approach, stone hardness (HU-Hounsfield units) should be considered in surgery planning

Analysis of Perioperative Events in Bilateral vs Unilateral Staged Percutaneous Nephrolithotomy

Introduction: Kidney stones are a common medical condition that impact approximately 10% of US population. Management of stone disease is based on size and location of stones. Percutaneous nephrolithotomy (PCNL) is typically indicated in patients with large renal stone burden (typically >2 cm) or complex anatomy. In the setting of complex stones, multiple, staged PCNLs are required. We hypothesize that there is no significant difference in the perioperative change in lab values in bilateral PCNLs compared to unilateral PCNLs.
 Methods: The data was gathered by retrospectively reviewing the electronic medical record of 50 patients in the IU health system who underwent planned staged PCNLs between January and December 2018. We identified patients who underwent both bilateral and unilateral staged procedures. Data for BMI, sex, ethnicity, hemoglobin, estimated glomerular filtration rate (GFR) (typically formula CKD-EPI or MDRD), urine and stone cultures, stone composition, and bilaterality vs. unilaterality was collected. Two-tailed T-tests were performed to analyze data between bilateral and unilateral cases.
 Results: We identified a total of 50 patients, 19 men vs. 31 women; 9 men and 10 women underwent bilateral PCNLs, while 11 men and 20 women had unilateral PCNLs. BMI ranged from 14.2 to 62.3, and age ranged from 15 to 81. Significant differences were found between the changes in hemoglobin levels in patients who underwent bilateral PCNLs when compared to unilateral PCNLs (p value 0.018). No significant differences were noted when comparing changes of estimated GFR, BMI, age or any other variables.
 Conclusion: Patients who underwent bilateral staged PCNLs demonstrated a greater drop in perioperative hemoglobin compared to unilateral PCNLs without an increase in blood transfusion. This finding suggests that Bilateral PCNLs requiring multiple stages are safe in complex stone patients.

Application of novel burst wave lithotripsy and ultrasonic propulsion technology for the treatment of ureteral calculi in a bottlenose dolphin (Tursiops truncatus) and renal calculi in a harbor seal (Phoca vitulina)

Marine mammals may develop kidney stones, which can be challenging to treat. We describe burst wave lithotripsy (BWL) and ultrasonic propulsion to treat ureteral calculi in a 48-year-old female bottlenose dolphin (Tursiops truncatus) and to reduce renal stone burden in a 23-year-old male harbor seal (Phoca vitulina). BWL and ultrasonic propulsion were delivered transcutaneously in sinusoidal ultrasound bursts to fragment and reposition stones. Targeting and monitoring were performed with real-time imaging integrated within the BWL system. Four dolphin stones were obtained and fragmented ex vivo. The dolphin case received a 10-min and a 20-min BWL treatment conducted approximately 24 h apart to treat two 8–10 mm partially obstructing right mid-ureteral stones, using oral sedation alone. For the harbor seal, while under general anesthesia, retrograde ureteroscopy attempts were unsuccessful because of ureteral tortuosity, and a 30-min BWL treatment was targeted on one 10-mm right kidney stone cluster. All 4 stones fragmented completely to < 2-mm fragments in < 20 min ex vivo. In the dolphin case, the ureteral stones appeared to fragment, spread apart, and move with ultrasonic propulsion. On post-treatment day 1, the ureteral calculi fragments shifted caudally reaching the ureteral orifice on day 9. On day 10, the calculi fragments passed, and the hydroureter resolved. In the harbor seal, the stone cluster was observed to fragment and was not visible on the post-operative computed tomography scan. The seal had gross hematuria and a day of behavior indicating stone passage but overall, an uneventful recovery. BWL and ultrasonic propulsion successfully relieved ureteral stone obstruction in a geriatric dolphin and reduced renal stone burden in a geriatric harbor seal.

Management of Renal Stone Burden in Horseshoe Kidney Using Flexible Scope Technology via Nephrostomy Tract

Management of Renal Stone Burden in Horseshoe Kidney Using Flexible Scope Technology via Nephrostomy Tract

Fully Automated Longitudinal Assessment of Renal Stone Burden on Serial CT Imaging Using Deep Learning.

Purpose: Use deep learning (DL) to automate the measurement and tracking of kidney stone burden over serial CT scans. Materials and Methods: This retrospective study included 259 scans from 113 symptomatic patients being treated for urolithiasis at a single medical center between 2006 and 2019. These patients underwent a standard low-dose noncontrast CT scan followed by ultra-low-dose CT scans limited to the level of the kidneys. A DL model was used to detect, segment, and measure the volume of all stones in both initial and follow-up scans. The stone burden was characterized by the total volume of all stones in a scan (SV). The absolute and relative change of SV, (SVA and SVR, respectively) over serial scans were computed. The automated assessments were compared with manual assessments using concordance correlation coefficient (CCC), and their agreement was visualized using Bland-Altman and scatter plots. Results: Two hundred twenty-eight out of 233 scans with stones were identified by the automated pipeline; per-scan sensitivity was 97.8% (95% confidence interval [CI]: 96.0-99.7). The per-scan positive predictive value was 96.6% (95% CI: 94.4-98.8). The median SV, SVA, and SVR were 476.5 mm3, -10 mm3, and 0.89, respectively. After removing outliers outside the 5th and 95th percentiles, the CCC measuring agreement on SV, SVA, and SVR were 0.995 (0.992-0.996), 0.980 (0.972-0.986), and 0.915 (0.881-0.939), respectively Conclusions: The automated DL-based measurements showed good agreement with the manual assessments of the stone burden and its interval change on serial CT scans.

Extracorporeal shock wave lithotripsy for treatment of large pediatric renal pelvic stone burden more than 2 cm

The high recurrence rates in pediatric urolithiasis indicate the need for none invasive or a minimally invasive treatment such as SWL. Therefore, EAU, ESPU and AUA recommend SWL as a first line treatment for renal calculi ≤ 2, and RIRS or PCNL for renal calculi > 2cm. SWL is superior to RIRS and PCNL as it is inexpensive, outpatient procedure, and it has a high SFR in well selected cases specially pediatrics. On the other hand, SWL therapy has a limited efficacy with a lower SFR, and high retreatment rate and/or additional interventions for treatment of larger and harder renal calculi. We carried out this study to evaluate the efficacy and safety of SWL for treatment of renal stones > 2cm to extend its indications for pediatric renal calculi. Between January 2016 and April 2022, we reviewed the records of patients with renal calculi treated by SWL, mini-PCNL, RIRS and open surgery in our institution. Forty-nine eligible children aged 1-5 years old, presented with renal pelvic and/or calyceal calculi measuring 2-3.9cm and underwent SWL therapy were picked up and participated in the study. The data of an additional eligible 79 children with the same age and had renal pelvic and/or calyceal calculi > 2cm up to stag horn calculi and underwent mini-PCNL, RIRS and open renal surgery were also picked up and participated in the study. We retrieved the following preoperative data from the records of the eligible patients; age, gender, weight, length, radiological findings (stone size, side, site, number and radio-density), renal function tests, routine laboratory findings, and urine analysis. The outcomes data in the form of; operative time, fluoroscopy time, hospital stay, SFRs, retreatment rates and complication rates were also retrieved from the records of patients treated with SWL and other techniques. Also, we collected the SWL characteristics in terms of; position, number and frequency of shocks, voltage, time of the session and U/S monitoring to assess stone fragmentation. All SWL procedures were performed according to the institution's standards. The mean age of patients treated with SWL was 3.23±1.19 years old, the mean size of the treated calculi was 2.31±0.49 and the mean length of the SSD was 8.2±1.4cm. All patients had NCCT scan and the mean radio-density of the treated calculi was 572 ± 169.08 HUs based on NCCT scans Table (1). Single- and two-session SFRs of SWL therapy were 75.5% (37/49 patients) and 93.9% (46/49 patients), respectively. The overall success rate was 95.9% (47/49 patients) after three-session of SWL. Complications experienced by 7 patients (14.3%) in the form of fever (4.1%), vomiting (4.1%), abdominal pain (4/1%), and hematuria (2%). All complications were managed in outpatient settings. Our results were obtained on the basis of preoperative NCCT scans for all patients and postoperative plain KUB films and real-time abdominal U/S. Furthermore, single-session SFRs for SWL, mini-PCNL, RIRS and open surgery were 75.5%, 82.1%, 73.7% and 90.6%, respectively. Two-session SFRs by the same technique were 93.9%, 92.8%, and 89.5% for SWL, mini-PCNL and RIRS, respectively. A lower overall complication rate and higher overall SFR were found with SWL therapy compared to other techniques, Fig. (1). Being a non-invasive outpatient procedure with a low complication rate and good spontaneous passage of stone fragments is the main advantage of SWL. In this study, the overall SFR is 93.9% where 46 out of 49 patients were completely rendered stone free after three session of SWL with overall success rate 95.9%. Badawy etal. reported overall success rates of 83.4% for renal stones with a mean stone size of 12.5±7.2mm. In children with renal stones measuring 18.2mm, Ramakrishnan etal. reported a 97% SFR in accordance with our results. The high overall success rate (95.9%) and SFR (93.9%) in our research were attributed to the regular use of ramping procedure, low shock wave rate, percussion diuretics inversion (PDI) approach and alpha blocker therapy in all participants and short SSD. The limitations of our study are small sample of patients and its retrospective nature. The non-invasive nature and replicability of the SWL procedure, along with the high success and low complication rates, give us a new insight to consider its application for treating pediatric renal calculi > 2cm over the other more invasive techniques. Short SSD, the use of ramping procedure, low shock wave rate, 2min break, PDI approach and alpha blockers therapy help better success of SWL. IV.

A dual neglected double J stent: a rare case report

BackgroundA neglected ureteric stent with encrustations is an uneasy problem for the patient and treating urologist. We report a rare case of single urinary system retained dual ureteric stents that was complicated by extensive encrustation.Case presentationA 36-year male patient referred from prison hospital with intermittent left loin pain and burning micturition. Pelvi-abdominal ultrasonography, plain X-ray and non-contrast computed tomography revealed neglected dual double J stents on the left side with large renal and urinary bladder stone burden and heavy ureteral encrustation. Staged endoscopic management was planned. At first session, both bladder and renal calculus was fragmented and removed by mechanical cystolithotripsy and percutaneous nephrolithotomy, respectively. After one week; the lower, middle and upper ureteral encrustations were cleared carefully using Holmium YAG Laser lithotripsy through 7 Fr. distal tip semi-rigid ureteroscopy. Both neglected double J were removed successfully and the patient was asymptomatic.ConclusionsNeglected ureteral stents are complicated by massive encrustation and need combined staged endoscopic procedures. Patient and health service provider should be learned for importance of stent removal.

Prospective, Randomized Comparison of Dual-Lumen vs Single-Lumen Flexible Ureteroscopes in Proximal Ureteral and Renal Stone Management.

Introduction: We sought to compare the safety, efficacy, efficiency, and surgeon experience during upper urinary tract stone management with single-lumen (SLFU) vs dual-lumen flexible ureteroscopes (DLFU). Materials and Methods: Seventy-nine patients with proximal ureteral or renal stone burden <2 cm were randomized to a SLFU or DLFU. We recorded times for ureteroscopy (URS), laser lithotripsy, stone basketing, as well as intraoperative and postoperative complications. The rate of stone clearance and stone free status were calculated using CT imaging. Surgeons completed a survey after each procedure rating various metrics regarding ureteroscope performance. Results: Thirty-five patients from the single-lumen group and 44 patients from the dual-lumen group had comparable median URS time (37 vs 35 minutes, p = 0.984) and basketing time (12 vs 19 minutes; p = 0.584). Median lithotripsy time was decreased in the dual-lumen group (single: 6 vs dual: 2 minutes, p = 0.017). The stone clearance rate was superior in the dual-lumen group (single: 3.7 vs dual: 7.1 mm3/min, p = 0.025). The absolute stone-free rate (SFR) was superior for the dual-lumen group (single: 26% vs dual: 48%, p = 0.045). No differences in intraoperative (single: 0% vs dual: 2%; p = 0.375) and postoperative complications (single: 7% vs dual: 11%, p = 0.474) were observed. Surgeons' ratings of the dual-lumen ureteroscope was superior for visibility, comfort, ease of use, and overall performance. Conclusions: The use of the dual-lumen ureteroscope in patients with renal and proximal ureteral stones <2 cm provided shorter lithotripsy time, higher stone clearance rates, improved SFR, and superior surgeon ratings when compared with SLFUs.

Ultramini-percutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of 10-30mm calculi: a randomized controlled trial.

The surgical management of renal stones 10-30mm is usually performed with percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). Standard form of percutaneous nephrolithotomy has paved the way for miniaturized PCNL in many centres. We wanted to evaluate the efficacy, safety and the cost-effectiveness of ultramini-percutaneous nephrolithotomy (UMP) versus RIRS in the treatment of renal stones with stone burden 10-30mm. Patients with renal stone burden 10-30mm were prospectively randomized into either UMP or RIRS. The demographic data, stone characteristic, operative time and cost of the equipment were recorded. The stone free status, analgesic requirement, deterioration of the renal function and hemoglobin and the postoperative complications as per Clavein-Dindo grade were recorded. One hundred and fifty patients met inclusion criteria. Out of these 98 underwent UMP and 46 RIRS. Six withdrew the consent before the procedure. Mean stone size was comparable in either of the groups. Mean laser time and stone extraction time was significantly less for UMP compared to RIRS (41.17min versus 73.58min p < 0.0001). Mean consumable costs in the UMP group were considerably less at US$45.73 compared to the RIRS group at $423.11 (p < 0.0001). The stone free rates at 1 month of follow-up were 100% for UMP group and 73% for RIRS group. There were insignificant changes to mean hemoglobin and glomerular filtration rate (GFR) in all patients and the average length of the stay was similar in both the groups. The postoperative complications revealed Grade I and II rate of 10% in the UMP group and 35% in the RIRS group, respectively. We concluded that UMP to be safe, effective and more economical to the RIRS for renal stones up to 3cm in size.Trial registered with ISRCTN registry ID ISRCTN20935105, Retrospective.

Is spinal anesthesia a safe alternative for retrograde intrarenal surgery for stone disease in daily practice?

Retrograde intrarenal surgery (RIRS) is commonly performed under general anesthesia (GA) because renal mobility during breathing may affect lithotripsy. However, spinal anesthesia (SA) is adopted in clinical practice due to clinical conditions that contraindicate GA. We aimed to compare results of RIRS for stones performed under GA compared to SA regarding stone-free rate (SFR) status and postoperative complications in a consecutive single-center series. We retrospectively reviewed all patients who underwent RIRS for stones between 2017 and 2020. age ≥ 18 years, renal stone burden deemed suitable for RIRS with a stone diameter ≤ 20 mm. stones >20 mm, urinary tract infection, bilateral surgery, second-look procedures, unmodifiable bleeding diathesis, <5mm asymptomatic lower calyx stones. SFR was defined as no residual fragment >3 mm at 6-12 weeks follow-up. The choice of anesthesia was a shared decision between anesthesiologists and patient preference. 230 patients were included in the analysis. Mean age was 57.50±13.73 years. 33% of stones were located in the pelvis. 28.7% of patients had multiple stones. Mean cumulative stone diameter was 16.60±6.54 mm. 63% of patients underwent RIRS under SA. There were no significant differences between the two groups in terms of preoperative characteristics, except for comor-bidity, significantly higher in the GA group. Mean time of operating room occupation was longer in the GA group (81.58±35.37 minutes) than in the SA group (72.85±25.91 minutes,p=0.033). Length of stay was shorter in the SA group (mean 2.2±1.66 days vs 3.46±5.88 in GA,p=0.019). Logistic regression showed that multiple stones in the collecting system were associated with residual fragments (HR 0.386, 95%CI 0.151-0.991,p=0.04). There were no statistically significant differences in overall and high-grade complications, and in SFR between SA (75.9%) and GA groups (70.6%,p=0.317). SA does not affect SFR and postoperative complications in patients who underwent RIRS in daily practice.

PD25-08 PREDICTORS OF INDEX PERCUTANEOUS NEPHROLITHOTOMY CARE SETTING AND IMPACT ON PERIOPERATIVE OUTCOMES AND COST

You have accessJournal of UrologyHealth Services Research: Value of Care: Cost and Outcomes Measures II (PD25)1 Sep 2021PD25-08 PREDICTORS OF INDEX PERCUTANEOUS NEPHROLITHOTOMY CARE SETTING AND IMPACT ON PERIOPERATIVE OUTCOMES AND COST William French, Quoc-Dien Trinh, Roger Sur, and David Friedlander William FrenchWilliam French More articles by this author , Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author , Roger SurRoger Sur More articles by this author , and David FriedlanderDavid Friedlander More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002018.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is an appropriate treatment option for patients with a large renal stone burden or complex anatomy. Cost pressures and newer minimally invasive approaches have led to a migration away from the traditional inpatient care setting toward ambulatory surgical centers. However, it is unclear what clinical and non-clinical factors determine where patients receive their surgical care and whether perioperative outcomes and costs differ among these cohorts. We sought to identify predictors of index surgical care setting as well as perioperative outcomes and cost associated with these unique care settings following PCNL surgery. METHODS: All-payer data from the 2014 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify all patients undergoing an index PCNL. Patient demographics, regional data, 30-day revisit/reoperation rates, and total index/30-day costs were determined. Multivariable logistic regression adjusted for facility clustering was utilized to identify predictors of index surgical care setting and 30-day revisit/reoperation, while gamma generalized linear regression was used to compare index/30-day costs. RESULTS: Of the 747 patients undergoing PCNL, 314 (42.0%) received care in the inpatient setting compared to 433 (58.0%) in the ambulatory care setting at an adjusted mean cost of $11,904.66 vs. $8,876.438 (p<0.001). Predictors of receiving care in the ambulatory care setting included gender (female vs. male: OR 0.49, 95% CI 0.34-0.72; p<0.001), fewer comorbidities (CCI ³2 vs. 0: OR 0.41, 95% CI 0.24-0.68; p=0.01), insurance status (Uninsured vs. private: OR 0.10, 95% CI 0.04-0.27; p<0.001), and rural vs. metropolitan care setting (OR 22.36, 95% CI 6.46-77.38; p<0.001). The 30-day adjusted revisit/reintervention rate for cases performed in the ambulatory vs. inpatient setting was comparable (22.4% vs. 16.2%, p=0.9). Mean cost attributable to a 30-day revisit was $6,918.13. CONCLUSIONS: We demonstrated that both clinical and non-clinical factors predict where patients undergo PCNL, with patients receiving care in the ambulatory setting experiencing dramatically lower costs but comparable 30-day perioperative outcomes. Our findings suggest that ambulatory-based PCNL offers significant cost savings without compromising 30-day outcomes in appropriately selected patients. Source of Funding: Quoc-Dien Trinh is supported by the Brigham Research Institute Fund to Sustain Research Excellence, the Bruce A. Beal and Robert L. Beal Surgical Fellowship, the Genentech Bio-Oncology Career Development Award from the Conquer Cancer Foundation of the American Society of Clinical Oncology, a Health Services Research pilot test grant from the Defense Health Agency, the Clay Hamlin Young Investigator Award from the Prostate Cancer Foundation, and an unrestricted educational grant from the Vattikuti Urology Institute. David F. Friedlander is supported by a National Institutes of Health T32 training grant © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e434-e435 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information William French More articles by this author Quoc-Dien Trinh More articles by this author Roger Sur More articles by this author David Friedlander More articles by this author Expand All Advertisement Loading ...

Factors Affecting Post Nephrostomy Removal Urinary Leakage after Percutaneous Nephrolithotomy (PCNL)

Background: Prolonged urinary leakage after nephrostomy tube removal leads to increased morbidity of PCNL and increased hospitalization. Objective: To evaluate factors affecting post nephrostomy removal urinary leakage after percutaneous nephrolithotomy. Patients and Methods: One hundred eight (108) patients older than 18 years who underwent PCNL were studied prospectively. The reasons that can affect urinary leakage postoperatively were divided into 4 categories according to individual factors including age, gender, and body mass index; Renal factors; including, previous operation, history of ESWL, parenchymal cortical thickness, and grades of hydronephrosis; stone factor (stone burden); and surgical factors including the number of tracts, presence of double J stent, nephrostomy tube diameter and stay duration. These data were compared for postoperative urine leak. Results: Urinary leakage was revealed in 76 of 108 patients (70.3%). There was no statistically significant relationship between individual factors and urinary leakage (P &gt;0.05). Among renal factors, just parenchymal cortical thickness and grade of hydronephrosis were strongly related to the urinary leakage (P &lt;0.001). The renal stone burden did not affect urinary leakage (P &gt;0.05). Among surgical factors, placing of ureteral double-J stent highly minimized the incidence of urinary leakage (P&lt;0.001), and the urinary leakage significantly correlated with the increased diameter of the nephrostomy tube and staying duration (P&lt;0.05). Conclusion: After PCNL surgery, some factors show to influence post-PCNL urinary leakage. however most of the urinary leakage was treated conservatively, but it increases morbidity and hospitalization. Keywords: Percutaneous nephrolithotomy; postsurgical complications; risk-factor; leaking of urine

MP15-06 INDICATIONS FOR STENT OMISSION AFTER URETEROSCOPIC LITHOTRIPSY: A PROSPECTIVE TRIAL FROM THE REGISTRY FOR STONES OF THE KIDNEY AND URETER (RESKU)

You have accessJournal of UrologyStone Disease: Surgical Therapy III (MP15)1 Apr 2020MP15-06 INDICATIONS FOR STENT OMISSION AFTER URETEROSCOPIC LITHOTRIPSY: A PROSPECTIVE TRIAL FROM THE REGISTRY FOR STONES OF THE KIDNEY AND URETER (RESKU) Robert Fisher*, Kaitlan Cobb, David Friedlander, David Bayne, Seth Bechis, Helena Chang, Thomas Chi, Brian Duty, Jonathan Harper, Ian Metzler, Mathew Sorensen, Marshall Stoller, David Tzou, and Roger Sur Robert Fisher*Robert Fisher* More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , David FriedlanderDavid Friedlander More articles by this author , David BayneDavid Bayne More articles by this author , Seth BechisSeth Bechis More articles by this author , Helena ChangHelena Chang More articles by this author , Thomas ChiThomas Chi More articles by this author , Brian DutyBrian Duty More articles by this author , Jonathan HarperJonathan Harper More articles by this author , Ian MetzlerIan Metzler More articles by this author , Mathew SorensenMathew Sorensen More articles by this author , Marshall StollerMarshall Stoller More articles by this author , David TzouDavid Tzou More articles by this author , and Roger SurRoger Sur More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000840.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stent complications including pain, infection and discomfort are a significant source of emergency room visits in the post-operative period. Per AUA Guidelines, placement of a ureteral stent following ureteroscopy (URS) is at the urologist’s discretion. The risk/benefit calculation for routine use of ureteral stents following uncomplicated URS is controversial. We performed a multi-institutional study to investigate if ureteral stent omission is safe following URS compared to routine stenting. METHODS: From November 2018 to June 2019, a stent omission protocol was instituted at 5 academic centers for patients undergoing URS with laser lithotripsy and/or basketing by 6 fellowship trained endourologists. Inclusion criteria included: age ≥18 years, solitary ureteral stone ≤10 mm, total renal stone burden ≤15 mm with largest stone ≤10cm. Patients were excluded for solitary kidney or if a ureteral access sheath was used without pre-stenting. Data was collected prospectively via ReSKU (The Registry for Stones of the Kidney and Ureter) and was retrospectively reviewed. Analyzed outcomes included event rates of patient phone calls, unplanned emergency department or clinic visits, and unplanned operation. Bivariate differences in categorical and continuous variables between stented and unstented groups were examined using the Pearson's chi-squared and the students t-test, respectively. RESULTS: A total of 344 URS procedures were performed and 134/344 (39.0%) patients met inclusion criteria for ureteral stent omission. Of these candidates, 90 subjects (67%) had their stents omitted, while 44 (33%) deviated from the stent-less protocol. Deviation from the stent protocol did not vary by institution (20% vs. 37.5% vs. 60% vs. 50% vs. 40%; P>0.05). The total event rate (phone call, ED, OR, or clinic) was 19.1% for subjects with a stent versus 20.0% for subjects with a stent omitted (P>0.05); with the majority (30.7%) of these events being phone calls. CONCLUSIONS: In a multi-center prospectively collected study involving 344 individuals undergoing URS for nephrolithiasis, there was a similar proportion of stented and unstented subjects who called, presented to the ED or clinic, or required a return trip to the operating room following uncomplicated ureteroscopy for stone disease. Our findings suggest that ureteral stents can be safely omitted in properly selected adult patients. Source of Funding: National Institutes of Health grant (NIH P20-DK-116193). © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e206-e206 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Robert Fisher* More articles by this author Kaitlan Cobb More articles by this author David Friedlander More articles by this author David Bayne More articles by this author Seth Bechis More articles by this author Helena Chang More articles by this author Thomas Chi More articles by this author Brian Duty More articles by this author Jonathan Harper More articles by this author Ian Metzler More articles by this author Mathew Sorensen More articles by this author Marshall Stoller More articles by this author David Tzou More articles by this author Roger Sur More articles by this author Expand All Advertisement PDF downloadLoading ...

Microperc versus miniperc for the management of medium-sized renal stones: a comparative two-center clinical study

Objective To date, there is very little evidence directly comparing the outcomes between Mini-percutaneous nephrolithotomy and Micro-percutaneous nephrolithotomy. Because of this evidence gap, we wanted to compare miniperc and microperc with an ultimate purpose to determine which modality is preferred for different stone characteristics. Our hope is that these findings may help guide which technique is most suitable for a given renal stone burden. Patients and methods This is a retrospective collaborative multi-institutional study between Dortmund Teaching Hospital (Germany) and Modena University Hospital (Italy) in which we compared two matched groups of patients. The first group (32 patients) underwent miniperc for medium-sized renal stones in Dortmund, and the second group (19 patients) underwent microperc in Modena. Both groups were matched according to age, sex, BMI, and maximum stone diameter according to preoperative plain KUB films. Results The primary stone-free rates in the miniperc and microperc groups were similar (93.8 vs. 84.2%, P = 0.262). Mean operative time for miniperc was significantly shorter than that of microperc (45.6 ± 18.9 vs. 68.7 ± 35.2 min, P = 0.004). The overall complication rate was 11.7%, with no significant difference between the two groups (12.5% for miniperc vs. 10.5% for microperc, P = 0.604). Mean hospital stay in miniperc was significantly longer than that of microperc (4.7 ± 1.6 vs. 3 ± 1.5 days,P Conclusion Our current data show that microperc is emerging as an effective and safe treatment option for intermediate-sized kidney stones, with outcomes comparable even to miniperc, which is already a well-established treatment with high safety profile in experienced hands.

Spontaneous resolution of urinary calculi in a congenital solitary kidney: A case report

Spontaneous resolution of a large renal stone burden in adults is a rare occurrence with few reports in the last 50 years. Improved imaging techniques and understanding of the pharmacology of dissolution therapy have led to a better understanding of which stones have the potential for spontaneous passage or targeted dissolution via medical treatment. Less is known regarding stone outcomes in children, and anecdotes of pediatric patients spontaneously passing large stones has been widely propagated. Here we report a case of spontaneous resolution of a large renal stone burden in a child with a congenital solitary kidney.

Efficacy of intercostal nerve block with 0.25% bupivacaine in percutaneous nephrolithotomy: A prospective randomized clinical trial.

Introduction and Aim:Several techniques have been used to lower the morbidity of percutaneous nephrostomy (PCN) tube after percutaneous nephrolithotomy (PCNL). The outcomes of intercostal nerve block (ICB) versus peritubal block (PTB) with 0.25% bupivacaine to alleviate post-PCNL pain were compared.Materials and Methods:After obtaining an informed written consent and local institutional ethics clearance, 64 patients undergoing PCNL were computer randomized to receive either an intercostal block/ICB (Group I) or a peritubal block/PTB (Group II) using 0.25% bupivacaine infiltration, after termination of the procedure. They were evaluated for visual analog scale (VAS) score, first analgesic requirement, and the total analgesic demand along with fall in hematocrit, PCN indwelling time, blood transfusion rate, complications, and mean hospital stay in the postoperative period. The protocol was registered with CTRI/2018/03/012717.Results:Patients in both the groups were comparable on the basis of demographic data, preoperative renal function, stone burden, and hematocrit value. The mean VAS score at 6, 12, 24, and 48 h was significantly lower in the Group II versus Group I (P < 0.001). The total mean analgesic requirement was 160.16 and 103.13 mg of diclofenac sodium in Group I and Group II, respectively, which was significantly higher in Group I versus Group II (P < 0.001). The time to first analgesic demand was significantly higher in PT group (8.06 ± 1.99 h vs. 12.97 ± 1.96 h) in Group I/ICNB and Group II/PT, respectively (P < 0.001). Both the groups were comparable in terms of postoperative hematuria, hematocrit fall, nephrostomy site leak, hospital stay, need of blood transfusions, stone-free rate/retreatment rate, postoperative urinary tract infections, and overall complication rate (Modified Clavien–Dindo classification) which were not statistically significant.Conclusion:Post PCNL, PTB was associated with significantly lower post operative pain and discomfort versus ICB as demonstrated by the significantly lower DVAS pain scores, higher mean time to first analgesic demand and lower mean total analgesic demandt with ICB. Bupivacaine was a safe and effective local anesthetic agent for PTB in select patients for facilitating quick relief from the morbid postoperative pain and discomfort following PCNL.

THE EFFICACY AND SAFETY OF PERCUTANEOUS NEPHROLITHOTOMY IN CORRELATION WITH DIFFERENT RENAL STONE BURDENS

Background: The improvements in instruments and technique of percutaneous nephrolithotomy (PCNL) in the last 3 decades have led to expansion in its indications to include even the large and complex renal stone cases. Objective: To determine the efficacy and safety of PCNL in relation to stone complexity. Methods: In this prospective, clinical, interventional study, 51 patients with symptomatic renal stones of different sizes and locations, were admitted in our Urology Unit, fully evaluated and treated by our team with PCNL. For all the patient’s data collected were: age, gender, body mass index (BMI), previous renal surgery, pre-operative stone number, stone size, stone position, stone opacity, surgical approach, operative time, stone clearance rate, postoperative residual stones and complications, hospital stay and adjuvant therapy. By using different statistical methods, correlations were made to elicit the impact of stone size, stone position, stone opacity, BMI and previous renal surgery, operative time, stone free rate, complication rate and the need for auxiliary procedures. Results: In this study, the 51 included patients were 31 males and 20 females with a mean age 40.3 year. All the stones treated were over 2 cm in their longest diameter, with 58.8% of them were ≥ 3 cm, and mean stone size was 4.2±0.99 cm. The most prevalent site of stone was the lower calyx (39.2%), followed by (37.3%) as partial staghorn, while complete staghorn calculi constituted (11.8%). The final success rate of treatment was 86.3%. (60.8%) of the cases found to be stone free at immediate postoperative period. Auxiliary procedures were used in (27.5%) patients, to improve the stone clearance. Residual stones were ultimately remained in only (7.8%). Complications occurred in 11 patients (21.6 %). Conclusion: PCNL though demanding, is an effective and reasonably safe procedure for the treatment of different renal stone burdens. Size and position of stones in the calyceal system and past renal surgery were the main determinants of operative time, stone clearance, complication rate and the need for auxiliary procedures. Keywords: Renal stone, PCNL, stone complexity, stone free rate, complications Citation: Al-Azzawi IS, Mohammed Zaki AW, Jwaid HI, Salih SL, Al-Obaidi AA. The efficacy and safety of percutaneous nephrolithotomy in correlation with different renal stone burdens. Iraqi JMS. 2018; 16(4): 385-392. doi: 10.22578/IJMS.16.4.5

Outcome of Percutaneous Nephrolithotomy in the Management of Lower Pole Stones

Urolithiasis is a worldwide problem due to its high prevalence and recurrence. Percutaneous nephrolithotomy is a minimally invasive surgical option for the treatment of large renal stone burden greater than 20mm, staghorn calculi and lower pole calyceal stone greater than 10 mm. The objective of this study was to evaluate the safety and efficacy of percutaneous nephrolithotomy in the management of lower pole calyceal stones. Seventy patients who presented in between June 2013 and September 2017 with lower pole calyceal stones and lower calyceal stones with pelvic extension were included in the study. The operating time, the hospital stay, complications rate, stone clearance rate were all noted. Patients were followed up in three and six weeks with X-ray KUB and ultrasonography of abdomen. Seventy adult patients with lower pole calyceal stones underwent standard percutaneous nephrolithotomy. The mean age was 32 years (18-71 yrs). The mean stone size was 17.6 mm (15 -28 mm). The mean operating time was 62 minutes (48-124 mins) and hospital stay was 4.1 days(4-8 days). The stone clearance rate was 92.6% for stone <20mm and 90.7% stone size >20 mm. The complications noted were fever (8.5%), transient haematuria (20%), urine leak (5.7%), obstruction by residual fragments (5.7%) and one pseudoaneurysm(1.42%). Seven patients (10%) needed blood transfusion. Percutaneous nephrolithotomyis a safe, feasible and highly effective method for the treatment of lower pole calyceal stones.

Outcome of Percutaneous Nephrolithotomy in the Management of Lower Pole Stones

Background: Urolithiasis is a worldwide problem due to its high prevalence and recurrence. Percutaneous nephrolithotomy is a minimally invasive surgical option for the treatment of large renal stone burden greater than 20mm, staghorn calculi and lower pole calyceal stone greater than 10 mm. The objective of this study was to evaluate the safety and efficacy of percutaneous nephrolithotomy in the management of lower pole calyceal stones. Methods: Seventy patients who presented in between June 2013 and September 2017 with lower pole calyceal stones and lower calyceal stones with pelvic extension were included in the study. The operating time, the hospital stay, complications rate, stone clearance rate were all noted. Patients were followed up in three and six weeks with X-ray KUB and ultrasonography of abdomen.Results: Seventy adult patients with lower pole calyceal stones underwent standard percutaneous nephrolithotomy. The mean age was 32 years (18-71 yrs). The mean stone size was 17.6 mm (15 –28 mm). The mean operating time was 62 minutes (48-124 mins) and hospital stay was 4.1 days(4-8 days). The stone clearance rate was 92.6% for stone &lt;20mm and 90.7% stone size &gt;20 mm. The complications noted were fever (8.5%), transient haematuria (20%), urine leak (5.7%), obstruction by residual fragments (5.7%) and one pseudoaneurysm(1.42%). Seven patients (10%) needed blood transfusion.Conclusions: Percutaneous nephrolithotomy is a safe, feasible and highly effective method for the treatment of lower pole calyceal stones.Keywords: Lower calyx; lower pole stones; percutaneous nephrolithotomy; stone free rate.

Efficacy of the Retrograde Intrarenal Surgery in Renal Stone: An Initial Clinical Experience

Objective The management of renal stone has changed radically over the recent decades mainly due to increasing use of flexible ureteroscopy. We report our initial experience of retrograde intrarenal surgery (RIRS) in treating renal stones. Methods Twenty-five patients (13 males and 12 females) who underwent RIRS for renal stone by a surgen between March 2016 to December 2017 were retrospectively reviewed. We analyzed the patients’ age, gender, stone location, stone burden, operative time, hospital stay, double J stent indwelling duration, success rates, and incidence of complications. Results The mean age of the patients was 54.9 years (range, 29–87 years). The locations of renal stones were nine cases in the renal pelvis, 14 in the renal calyx, and three in the renal diverticulum. The mean body mass index was 25.2 kg/m2 (range, 21.2–29.4 kg/m2). After 1 week since initial session, stone free rate was 72%, but 88% at 3-month follow-up. The mean stone burden was 45.7 mm (range, 16.4–189.3 mm), and mean operative time was 95.0 minutes (range, 30–125 minutes). The mean hospital day was 3.5 days (range, 3–6 days). Double J stent was inserted in all patient during operation and mean indwelling duration was 6.96 days (range, 4–14 days). Most common complication was fever and recovered with conservative therapy. Conclusion This study demonstrated that RIRS is safe and effective procedure for management of intrarenal stones with minimal complications. Our study suggests that renal stone burden is significant factor of success rate in RIRS. However, surgical experience and long-term follow-up are needed to confirm the factor of success rate. Key words: Nephrolithiasis; Kidney; Ureteroscopy