Is retrograde intrarenal surgery a viable treatment option for renal stones in patients with solitary kidney?

Prevention, diagnosis, and treatment of urolithiasis in geriatric patients - differences, similarities and caveats in comparison to the general population

PURPOSE OF REVIEW

Purpose of the review is to address management and prevention of urolithiasis in elderly patients examining the dynamic interplay between general measures, dietary adjustments, lifestyle modifications, and targeted pharmacological and/ or surgical interventions. The goal is to provide understanding of the evolving strategies required for effective urolithiasis prevention in the geriatric population.

RECENT FINDINGS

Age-specific diagnostic considerations are necessary because urolithiasis in the elderly population is characterized by bigger stones, greater peri-operative risks, and heightened symptom severity. When comorbidities are present, conservative treatments - especially analgesia - provide difficulties. Surgical procedures prove to be safe and effective, with complication rates and practical application comparable to younger cohorts. Prevention approaches that include lifestyle changes and the investigation of novel pharmaceutical options such as sodium-dependent glucose co-transporter 2 (SGLT-2)-inhibitors are promising in the management of urolithiasis in the elderly population.

SUMMARY

Our review offers a thorough investigation of urolithiasis in the elderly population, elucidating distinct clinical manifestations, complex diagnostic issues, and treatment implications. The safety and effectiveness of ureteroscopy in older patients, as well as the possible prophylactic function of SGLT-2-I, offer crucial insights for clinicians. Subsequent studies are necessary to enhance age-specific therapies, addressing the distinct obstacles presented by urolithiasis in the elderly population within this rapidly growing demographic.

Safety and Efficacy of Retrograde Intrarenal Surgery in the Solitary Kidney: A Propensity Score-Matched Analysis of the RIRSearch Study Groups' Results

Background: The aim of this study was to evaluate the efficacy and safety of retrograde intrarenal surgery (RIRS) in patients with renal calculi with solitary kidneys (SKs). Materials and Methods: In this retrospective, multicenter study, a matched case-control study was carried out using the data from 522 RIRS patients treated between 2014 and 2021. Patients' demographic data, stone characteristics, operative outcomes, perioperative and postoperative complications, and surgical success were analyzed. All patients were evaluated with noncontrast-enhanced computed tomography (NCCT) preoperatively and 1 month after the surgery. Surgical success was defined as no evidence of remaining residual fragments of <3 mm in the first-month postoperative NCCT images. The case group of 29 patients with SKs (Group 1) treated with RIRS were matched with 76 control patients (Group 2) with bilateral kidneys, who underwent unilateral RIRS by propensity score-matched (PSM) analysis. Results: After PSM analysis, the demographic and clinical data did not differ significantly between the groups. The stone burden was similar between the groups: 733.6 mm3 (range: 50.4-7565.9) versus 991.1 mm3 (range: 201.2-4380.6) (P = .09), respectively. The perioperative complication rates were 13.8% (n = 4) in Group 1 and 11.8% (n = 9) in Group 2 (P = .78). There was no statistically significant difference between the groups for postoperative complication rates (minor complications, classified as Clavien 1 or 2), (6.9% [n = 2] versus 13.2% [n = 10; P = .34]), respectively. Surgical success was 82.8% (n = 24) in Group 1 and 83.6% in Group 2 (P = .92). There was no significant difference between preoperative and postoperative glomerular filtration rate and creatinine values (P = .005). Conclusions: Our results support that RIRS is a safe and effective treatment method in SK patients with similar complication and stone-free rates compared to patients who had bilateral functional kidneys and underwent unilateral RIRS.

Influencing factors of acute kidney injury following retrograde intrarenal surgery

PURPOSE

To investigate the influencing factors of acute kidney injury (AKI) following retrograde intrarenal surgery (RIRS).

METHODS

The data of patients who underwent RIRS for kidney stones between January 2018 and June 2022 at two tertiary centers were retrospectively analyzed. Demographic data of patients were obtained. According to kidney disease: Improving Global Outcomes (KDIGO) criteria, those with and without AKI were divided into two groups. Preoperative, intraoperative, and postoperative predictive factors of patients were investigated between the groups. In addition, the influencing factors of AKI were examined by multivariate analysis.

RESULTS

This study included 295 (35.7%) women and 532 (64.3%) men. The mean age was 50.03 ± 15.4 years (range 18-89), and mean stone size was 15.5 ± 6.1 mm (range 6-47). Overall, 672 of patients (81.3%) were stone-free after the initial treatment. According to KDIGO, 110 of patients (13.3%) had AKI during the postoperative period. Univariate analysis showed that stone size (P = .003), previous stone surgery (P = .010), renal malformations (P = .017), high operative time (P =  < .001), high preoperative creatinine value (P = .036), intraoperative complications (P = .018), and postoperative urinary tract infection (P = .003) had significant influence on the AKI after RIRS. Multivariate analysis excluded previous stone surgery, high preoperative creatinine value, renal malformations, and intraoperative complications from the logistic regression model, whereas other factors maintained their statistically significant effect on AKI, indicating that they were independent predictors.

CONCLUSIONS

Stone size, operative time, postoperative urinary tract infection, and diabetes mellitus are significant predictors of AKI. During RIRS, urologists should consider the factors that increase the risk of AKI and evaluate the treatment outcomes based on these factors.

Comparison between Retrograde Flexible Ureteroscopy and Percutaneous Nephrolithotomy for the Treatment of Renal Stones of 2-4 cm

Background and objectives: Renal stones are widespread, with a lifetime prevalence of 10% in adults. Flexible ureteroscopy enables urologists to treat lower calyx stones or even complex renal stones through the natural orifice and achieve an acceptable stone-free rate. Hence, we analyzed the effectiveness and safety of FURS versus PCNL in treating renal stones between 20 and 40 mm in diameter. Materials and methods: We retrospectively analyzed 250 consecutive patients with large renal solitary stones (stone burden between 2 and 4 cm) from 1 January 2019 to 31 December 2020. The patients were divided into two groups: group 1 (125 patients), in which the patients were treated by a retrograde flexible ureteroscopic approach, and group 2 (125 patients), in which we used percutaneous nephrolithotomy. Stone characteristics and anatomical data were observed based on the computed tomography (CT) and/or KUB (Kidney-ureter-Bladder) radiography imaging archive. Results: The mean stone burden was 26.38 ± 4.453 mm in group 1 and 29.44 ± 4.817 mm in group 2. The stone-free rate after the first ureteroscopy was higher for the PNL(percutaneous nephrolithotomy) group (90.4%) than the F-URS group (68%). After two sessions of ureteroscopy, the SFR was 88.8% in the first group, and after three procedures, the SFR rose to 95.2%. The overall complication rate was higher in group 1 than in group 2 (18.4% vs. 16.8%), but without statistical relevance (p > 0.5). Furthermore, we encountered more grade III and IV complications in the PNL group (8.8% vs. 4.8%, p < 0.05). Conclusion: Flexible ureteroscopy proves to be efficient in treating renal stones over 2 cm. However, the patients must be informed that more than one procedure might be necessary to overcome the entire stone burden.

SIMULTANEOUS BILATERAL ENDOSCOPIC SURGERY (SBES): IS IT READY FOR PRIME TIME?

Introduction To date, some data available in literature on simultaneous bilateral endoscopic surgery (SBES) have shown good outcomes in terms of both effectiveness and safety. The aim of this study was to report the outcomes pertaining to the effectiveness and safety of SBES performed in our series of patients with bilateral renal stones. Materials and Methods A prospective analysis of consecutive patients who underwent SBES for bilateral renal stones at our institution between June 2017 and September 2021 was performed. Routine preoperative and 1-month postoperative work-up included history, physical examination, urinalysis, urine culture, and blood tests, including the evaluation of estimated glomerular filtration rate (eGFR) using the Cockcroft-Gault equation. An abdominal non-contrast computerized tomography (NCCT) scan was performed in all cases preoperatively and 1-month postoperatively. Peri/postoperative complications were reported according to the Clavien-Dindo classification system. The primary endpoint of the study was stone-free rate (SFR), and the secondary endpoints were Clavien-Dindo complications grade 1 or higher. Results Altogether, 101 patients met the inclusion criteria and were enrolled in the study. SFR for all renal units was achieved in 82 patients (81.1%) at the 1-month follow-up. Twelve patients underwent additional flexible ureteroscopy for residual fragments, and seven asymptomatic patients with single small residual fragment were observed. Eighteen patients (17.8%) experienced Clavien-Dindo Grade I-II complications, whereas one patient (1%) experienced Clavien-Dindo Grade IIIa complication (renal arteriovenous fistula embolization under local anesthesia). Conclusions SBES is a safe and effective procedure for the treatment of bilateral renal stones. Further randomized studies with larger populations are needed to confirm these favorable outcomes of SBES to establish it as an alternative to staged surgeries in patients with bilateral renal stones. Appropriate patient selection is of paramount importance for achieving good outcomes without experiencing severe complications.

Retrograde intrarenal surgery for the treatment of renal stones in patients with a solitary kidney: Does access sheath matter?

Background

Treating renal stones in patients with a solitary functioning kidney is challenging. The present study was aimed to assess the competence and safety of retrograde intrarenal surgery (RIRS) for the treatment of renal stones in a solitary kidney.

Methods

Between August of 2017 and August of 2019, 25 ensuing patients with a solitary kidney and renal calculi and who were treated with RIRS were prospectively enlisted in the study. All patients were assessed by non-contrast computed tomography before surgery. Stone-free status was determined if there were no residual fragments. The final stone-free rates (SFRs) were assessed 3 months after the last treatment session by plain X-ray KUB and ultrasonography. Patient demographics, perioperative and postoperative outcomes were prospectively evaluated. Serum creatinine levels and glomerular filtration rate (GFR) pre-procedure and during follow-up were correlated.

Results

Twenty-five patients underwent 26 procedures. The mean patient age was 42.81 ± 12.3 (range 22–67) years. The mean stone size was 18.23 ± 6.27 mm (range 9–25 mm) and the mean operative time was 46.15 ± 15.34 min (range 25–100 min). A ureteral access sheath (UAS) was used in five (19.2%) pre-stented patients. One patient (3.8%) required the second stage RIRS for residual stones. The SFR after the initial and final procedures, the SFR was 84% and 92%, respectively.

The mean serum creatinine levels were significantly reduced post-surgery compared to preoperative levels (1.76 ± 1.21 mg/dL; 1.37 ± 0.60 mg/dL; p value 0.001) while GFR not encounter any significant variation post-surgery (63.04 ± 33.16 ml/min) compared to preoperative rates (61.12 ± 34.76 ml/min, p value 0.502). Minor complications classified as Clavien I or II developed in 5 patients (20%). Clavien IIIb, a major complication, developed in one (4%) patient, which was caused by steinstrasse and necessitated emergency surgical intervention.

Conclusion

Renal stones in a solitary kidney can be managed using RIRS safely and effectively with and without the use of UAS, without compromising renal function.

Do we have a limit for retrograde intrarenal surgery for solitary kidney stone?

OBJECTIVE

The management of urolithiasis in patients with a solitary kidney is challenging for urologists. This study aimed to evaluate the safety of retrograde intrarenal surgery (RIRS) in the treatment of stones in patients with solitary kidney and to reply to the question if there is any limit for this surgery.

METHODS

Between January 2016 and December 2019, we enrolled 52 patients who had a solitary kidney and underwent RIRS. We collected data on preoperative patient characteristics, stone dimensions, and postoperative outcomes. Stone size, duration of operation, duration of fluoroscopy, type of anesthesia, and degree of surgical complication were evaluated retrospectively. Surgeries performed in less and more than 60 minutes and with and without complications were compared.

RESULTS

A total of 52 patients with a kidney stone and a solitary kidney were evaluated. The mean stone size was 14 ± 0.4 cm and surgical success rate was 87.3%. In our study, 13 patients (24.5%) had grade 1 minor complications, and none required a blood transfusion. The mean operation time was 51.9 ± 17.3 minutes. The postoperative creatinine value increased in 6 patients. The duration of operation in the group with complications was significantly higher than that in the group without complications. In patients who underwent an operation lasting ≥ 60 minutes, stone size, fluoroscopy time, and complication rate were significantly higher than in patients who underwent an operation lasting ≤ 60 minutes.

CONCLUSION

Our opinion is to be careful in patients with a solitary kidney with a big stone and we recommend assigning these procedure to experienced hands for not exceeding 60 minutes in one session.

The feasibility of one-stage flexible ureteroscopy lithotripsy in solitary kidney patients with 1-3 cm renal stones and risk factors of renal function changes

Purpose

To compare perioperative outcomes and long-term renal function changes between prior stenting (PS) and not prior stenting (NPS) before flexible ureteroscopy lithotripsy (f-URS) for solitary kidney patients.

Methods

Solitary kidney patients with 10–30 mm renal stones were enrolled in this historical control study. Perioperative parameters and complications were compared. Stone-free was defined as the absence of any residual stones on a CT scan. Renal function changes were evaluated by estimated glomerular filtration rate (eGFR) and adjusted for body surface area. A decrease in the eGFR over 20% was identified as ‘deterioration’ in renal function. The follow-up period was at least 6 months. Logistic regression was used to identify risk factors of renal function deterioration.

Results

Of the 76 patients included, 40 cases experienced prior stenting before f-URS. The average stone diameter was 16.8 ± 4.7 mm, ranging from 10.0 to 28.4 mm. Initial SFR was 85.0 and 83.3% in the PS and NPS groups, respectively (p = 0.842), while SFR after the second procedure was 97.5 and 94.4% (p = 0.926). Seven PS and 5 NPS patients developed complications (p = 0.666). At the postoperative 6 months, seven patients showed a deteriorated renal function. Surgical time in minutes was identified as a risk factor for renal function deterioration after the operation (OR = 1.061, 95% CI: 1.015–1.109, p = 0.009, per minute).

Conclusion

It appears that one-stage f-URS without PS could be feasible for 10–30 mm renal stones in solitary kidney patients, and less surgical time might be beneficial to protect renal function.

Effects of flexible ureteroscopy on kidney: A prospective clinical trial

OBJECTIVE

To investigate the effects of flexible ureteroscopy (F-URS) on the operated side of a kidney by assessing the renal damage markers, urine neutrophil gelatinase-related lipocalin (NGAL) and serum cystatin-C (Cys-C), and overall kidney function with the measurements of standard serum creatinine and urine albumin and protein levels.

MATERIAL AND METHODS

A total of 30 patients who underwent F-URS for treatment of upper urinary stone disease were prospectively evaluated. Preoperative serum urea, creatinine, and Cys-C levels were noted. Levels of urine albumin, protein, creatinine, and NGAL in spot urine samples from the operated side of a kidney obtained through the access sheath preoperatively and through the ureteral catheter 1 and 24 hours postoperatively were also measured. Preoperative and postoperative parameter levels were statistically compared.

RESULTS

The patients' mean age was 46.6±15.9 years. The mean operative and fluoroscopy times were 90.67±32.5 and 3.15±1.43 minutes, respectively. The urine creatinine, albumin, protein, albumin/creatinine, and protein/creatinine levels were similar in preoperative and postoperative periods. Postoperative serum urea, creatinine, and Cys-C levels and urine NGAL and NGAL/creatinine levels were not also found with remarkable changes from the baseline levels.

CONCLUSION

F-URS is a safe therapeutic intervention in the treatment of urolithiasis, especially regarding renal damage, and functional outcomes.

Endourologic Management (PCNL, URS, SWL) of Stones in Solitary Kidney: A Systematic Review from European Association of Urologists Young Academic Urologists and Uro-Technology Groups

Introduction: Urolithiasis in solitary kidney (SK) presents significant management dilemma as any insult to the kidney or its drainage can lead to significant morbidity. The treatment options include shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and ureteroscopy (URS). Our aim was to conduct a systematic review of literature on all available endourologic techniques reporting on the management of stones in an SK. Materials and Methods: We conducted a systematic review according to the Cochrane and PRISMA checklist for all English-language articles from inception to December 2018. All studies with a minimum of 10 patients that reported on endourologic management (SWL, PCNL, or URS) were included. Data were extracted for patient and stone demographics, outcomes including stone-free rate (SFR), adverse events, and renal function. Results: After an initial search of 553 articles, 27 were included for the final review (10 PCNL, 1 mini-PCNL, 9 URS, 1 SWL, and 6 comparative studies). The choice of treatment seemed to be based on stone size, with PCNL, URS, and SWL offered for mean stone sizes between 25-50, 10-28, and 12-15 mm, respectively. PCNL, URS, and SWL were reported in 1445, 792, and 186 patients, respectively, with a final SFR of 67%-97.7%, 43%-100%, and 73%-80% and a complication rate of 26.4%, 15%, and 16.7% across the three groups. The renal function deterioration was reported in 4/16 PCNL studies and in 1/15 URS studies, while it remained unaffected in the SWL study. Conclusions: Our review shows a rise of endourologic techniques in the management of stones in SK. Although PCNL was used for larger stones, it had a higher risk of major complications, including blood transfusion. While a good SFR was obtained for patients irrespective of the treatment modality, the selected intervention needs to be balanced with its safety profile and the need for ancillary procedures.

A case of allograft ureteral stone successfully treated with antegrade ureteroscopic lithotripsy: use of a 3D-printed model to determine the ideal approach

We present the case of a 46-year-old man who underwent successful antegrade ureteroscopy for lithiasis in his allograft ureter. At a scheduled follow-up 15 years after transplantation, computed tomography (CT) detected a 12-mm renal stone in the renal pelvis of the transplanted kidney. During his follow-up, gross hematuria was seen; the stone moved to the ureter, causing hydronephrosis. Ultrasound and non-contrast CT revealed hydronephrosis and a 15-mm stone in the transplanted ureter. Considering the stone size, location, and the difficulty of the access to the anastomosed ureteral orifice, percutaneous ureteroscopic approach was planned. Due to the anatomical difficulty regarding his allograft kidney, we planned to prepare a 3D image and model for selecting the best percutaneous approach. The procedure was performed and a stone-free status was acquired without complication. Under precise simulation, we performed successful antegrade ureteroscopy for lithiasis in the allograft ureter supported by 3D imaging. Use of a 3D printed model may aid in a safe and effective procedure for lithiasis in the allograft kidney and ureter.

Comparison of retrograde flexible ureteroscopy and percutaneous nephrolithotomy in treating intermediatesize renal stones (2-3cm): a meta-analysis and systematic review

Purpose:

To systematically assess the effectiveness and safety of retrograde flexible ureteroscopy (FURS) versus percutaneous nephrolithotomy (PCNL) in treating intermediate-size renal stones (2-3cm).

Materials and Methods:

PubMed, Ovid MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE were researched to identify relevant studies up to May 2018. Article selection was performed through the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. The Newcastle-Ottawa Scale was applied to assess the methodological quality of case-control studies.

Results:

Six retrospective case-controlled trials were included for meta-analysis. The pooled results showed that PCNL was associated with a higher initial stone-free rate (SFR). After more complementary treatments, FURS provided a final SFR (OR: 1.69; 95% CI, 0.93-3.05; P = 0.08) comparable to that achieved by PCNL. PCNL was associated with a higher rate of overall intraoperative complications (OR: 1.48; 95% CI, 1.01-2.17; P = 0.04) and longer hospital stay (MD: 2.21 days; 95% CI, 1.11 to 3.30; P < 0.001). Subgroup analysis by Clavien-graded complication showed PCNL had significantly higher rates of minor complications (OR: 1.58; 95% CI, 1.04-2.41; P = 0.03). No significant difference was noted in major complications (OR: 1.14; 95% CI, 0.53-2.45; P = 0.73) or operative times (MD: −9.71 min; 95% CI, −22.02 to 2.60; P = 0.12).

Conclusions:

Multisession FURS is an effective and safe alternative to PCNL for the management of intermediate-size renal stones (2-3cm). It is advisable to balance the benefits and risks according to the individual characteristics of patients and to decide with patients by discussing the advantages and disadvantages of each procedure.

A prospective multicenter European study on flexible ureterorenoscopy for the management of renal stone

Purpose

The aim of this study was to describe the outcomes and the complications of retrograde intrarenal surgery (RIRS) for renal stones in a multi-institutional working group.

Materials and Methods

From 2012 to 2014, we conducted a prospective study including all RIRS performed for kidney stones in 4 European centers. Demographic information, disease characteristics, and perioperative and postoperative data were gathered. Patients and stone data, procedure characteristics, results and safety outcomes were analyzed and compared by descriptive statistics. Complications were reported using the standardized Clavien system.

Results

Three hundred and fifty-six patients underwent 377 RIRS with holmium laser lithotripsy for renal stones. The RIRS was completed in all patients with a mean operative time of 63.5 min. The stone-free status was confirmed endoscopically and through fluoroscopic imaging after the first procedure in 73.6%. The second procedure was performed in twenty patients (5.6%) achieving an overall stone free rate of 78.9%. The overall complication rate was 15.1%. Intra-operative and post-operative complications were seen in 24 (6.7%) and 30 (8.4%) cases, respectively.

Conclusions

RIRS is a minimally invasive procedure with good results in terms of stone-free and complications rate.

RIRS in the elderly: Is it feasible and safe?

BACKGROUND

The aim of this study was to compare the safety and efficacy of RIRS in men ≥65 years to those <65 years.

MATERIALS AND METHODS

Patients who underwent RIRS were prospectively collected from March 2013 to March 2014 in 5 European centers. Perioperative outcomes and complications in elderly men were compared with men <65 years. Univariable and multivariable analyses were performed for factors predicting overall complications. The groups were compared using Mann-Whitney U test. Categorical variables were compared using chi-squared test and the Yates correction or the Fisher's exact test.

RESULTS

A total of 399 patients with renal stones were included, 308 (77.19%) were aged <65 years, 91 (22.8%) were aged ≥65 years. Elderly patients were more likely to have higher ASA scores (35.7% vs 92.3%; p < 001), Charlson Comorbidity Index (1.8 vs. 5.2, p < 0.001), hyperlipidemia (10.06% vs. 30.76%; p = 0,0005) and coronary heart disease (5.51% vs. 17.58; p = 0.005) compared to younger cohort. Perioperative outcomes (stone free rate, operative time and re-intervention rate) did not show differences between the two groups (p > 0.05). Surgical and medical complication rates were similar between the cohorts (14.28% vs 9.89%; p = 0.38). Multivariate analysis did not identify any predictive factors of complications among the two groups (p > 0.05).

CONCLUSIONS

In this study, elderly RIRS patients had comparable short term efficacy and perioperative complications to younger patients, despite a higher prevalence of comorbidity. Age itself should not be considered as a risk factor for the development of complications in patients undergoing RIRS for renal stone.

Percutaneous nephrolithotomy versus retrograde intrarenal surgery for the treatment of kidney stones up to 2 cm in patients with solitary kidney: a single centre experience

BACKGROUND

To compare the treatment outcomes between percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for the management of stones larger than 2 cm in patients with solitary kidney.

METHODS

One hundred sixteen patients with a solitary kidney who underwent RIRS (n = 56) or PCNL (n = 60) for large renal stones (>2 cm) between Jan 2010 and Nov 2015 have been considered. The patients' characteristics, stone characteristics, operative time, incidence of complications, hospital stay, and stone-free rates (SFR) have been evaluated.

RESULTS

SFRs after one session were 19.6% and 35.7% for RIRS and PCNL respectively (p = 0.047), but the SFR at 3 months follow-up comparable in both groups (82.1% vs. 88.3%, p = 0.346). The calculated mean operative time for RIRS was longer (p < 0.001), but the mean postoperatively hospital stay was statistically significantly shorter (p < 0.001) and average drop in hemoglobin level was less (p = 0.040). PCNL showed a higher complication rate, although this difference was not statistically significant.

CONCLUSIONS

Satisfactory stone clearance can be achieved with multi-session RIRS in the treatment of renal stones larger than 2 cm in patients with solitary kidney. RIRS can be considered as an alternative to PCNL in selected cases.

Factors affecting complication rates of retrograde flexible ureterorenoscopy: analysis of 1571 procedures-a single-center experience

PURPOSE

To evaluate the factors affecting complication rates of flexible ureteroscopy and laser lithotripsy (FURSL).

MATERIALS AND METHODS

Data on a total of 1395 patients, with 1411 renal units underwent 1571 procedures with FURSL for renal and/or proximal ureteral stones between April 2012 and January 2016, were retrospectively analyzed. Complications were assessed using the Satava and modified Clavien systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates.

RESULTS

The mean patient age in the total procedures was 45.68 ± 14.00 years (range 2-86 years), and the mean stone size was 15.15 ± 8.32 mm (range 5-75 mm). The overall success rate was 95.6 %. A total of 209 (13.3 %) cases suffered from complications with intraoperative complications rates of 5.9 % and postoperative complication rates of 7.3 %. Univariate analysis revealed no significant difference in complication rates in respect of age, gender, body mass index, use of ureteral access sheath, operation time, bleeding disorder, solitary kidney, preoperative stenting, American Society of Anesthesiologists score, repeated procedure or location of stones (all p value >0.05). Complication rates were determined to be significantly affected by stone size (p = 0.026), multiplicity (p = 0.028) and the presence of congenital renal abnormality (p < 0.01). The only significant factor in multivariate analysis was the presence of congenital renal abnormalities (p = 0.02).

CONCLUSIONS

The results of the current study indicated that stone size, stone number and the presence of congenital renal abnormalities were factors affecting complication rates after FURSL, although congenital renal abnormality was the only independent predictor among these risk factors.

A Fatal Mycotic Sepsis after Retrograde Intrarenal Surgery: A Case Report and Literature Review

Purpose

The retrograde intrarenal surgery (RIRS) is a procedure that sees an increase in its use every day and is supported by excellent results in terms of safety and feasibility. We report the first case of fatal mycotic septic complication in a neurological patient for renal stone disease.

Case Presentation

The case of a woman 44 year-old, with left solitary kidney and history of advanced multiple sclerosis, epilepsy, bedridden and percutaneous endoscopic gastrostomy was described. She was hospitalized for the presence of recurrent lower urinary tract infections. The computed tomography (CT) scan control revealed a 1.7 cm obstructive renal pelvic stone and multiple stones in the bladder. After the refusal of a percutaneous approach, a RIRS was planned and done. No intraoperative complications were observed. In the postoperative period, she developed a urinary sepsis with progressive deterioration of the general conditions. She died 6 days after the RIRS for septic shock with a blood culture positive for Candida glabrata.

Discussion

A Pubmed search for fatal complications after RIRS shows only two cases not fully elucidated.

Conclusions

The use of flexible ureteroscopes and holmium lasers has a high succes rate;nevertheless, the possibility of a major complication should be kept in mind in order to evaluate all the risk factors, to adopt all the preventive measures for the safety of the patients.

Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks

BACKGROUND

Thanks to advancements in the endoscopic armamentarium, flexible ureteroscopy (fURS) has become a viable and attractive option for the treatment of renal stones because of its high stone-free rates (SFRs) and low morbidity.

OBJECTIVE

To describe our surgical technique for fURS, step-by-step, for the treatment of renal stones and to assess its effectiveness and safety.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of 316 consecutive patients who underwent fURS for renal stones at our institution between March 2014 and September 2015 was performed.

SURGICAL PROCEDURE

Ureteroscopy and laser lithotripsy using a standardized technique with last-generation flexible ureteroscopes.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Clinical data were collected in a dedicated database. Intraoperative and postoperative outcomes were assessed. A descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

The mean overall stone size was 16.5 ± 7.9mm. Ureteral access sheath placement was possible in 287 patients (90.8%). At 1-mo follow-up, the overall primary SFR was 79.1%; the secondary and tertiary SFRs were 89.5% and 91.5%, respectively. The mean operative time was 72.6 ± 27.5min. The mean number of procedures was 1.27. Complications were reported in 92 patients (29.1%) overall, with Clavien grade 1 in 55 patients (17.4%), grade 2 in 30 patients (9.5%), grade 3 in 6 patients (1.9%), grade 4 in 1 patient (0.3%), and grade 5 in none. The main limitation of the study was the retrospective nature.

CONCLUSIONS

The fURS procedure is safe and effective for the treatment of renal stones. A staged procedure is necessary to achieve stone-free status with large calculi.

PATIENT SUMMARY

Flexible ureteroscopy is an effective treatment with low complication rates for the majority of renal stones. Both the modern highly technological armamentarium and surgical know-how should be available.

Outcomes of ureteroscopy for patients with stones in a solitary kidney: evidence from a systematic review

INTRODUCTION

Management of urolithiasis in a solitary functioning kidney can be clinically challenging. The aim of this article was to review the outcomes of URS for patients with stone disease in a solitary kidney and critically appraise the existing evidence and outcome reporting standards.

MATERIAL AND METHODS

We conducted a systematic review in line with PRISMA checklist and Cochrane guidelines between January 1980 and February 2015. Our inclusion criteria were all English language articles reporting on a minimum of 10 patients with a solitary kidney undergoing ureteroscopy for stone disease.

RESULTS

A total of 116 patients (mean age 50 years) underwent URS for stones in solitary kidney. For a mean stone size of 16.8 mm (range: 5-60 mm) and 1.23 procedures/patient, the mean stone free rate was 87%. No significant change in renal function was recorded in any of the studies although a transient elevation in creatinine was reported in 10 (8.6%) patients. A total of 33 (28%) complications were recorded a majority (n = 21) of which were Clavien grade I. The Clavien grade II/III complications as reported by authors were urosepsis, steinstrasse and renal colic. None of the procedures required conversion to open surgery with no cases of renal haematoma or ureteric perforation.

CONCLUSIONS

This contemporary review highlights URS as a viable treatment option for stone disease in patients with a solitary kidney. It is associated with superior clearance rates to SWL and fewer high-risk complications compared to PCNL.

Safety and feasibility of day case ureteroscopy and laser lithotripsy (URSL) in patients with a solitary kidney

Introduction

The management of nephrolithiasis in patients with a solitary kidney poses a treatment challenge. The study aimed to evaluate the outcomes of ureteroscopy and laser stone fragmentation (URSL) for renal stones in these patients treated in our university teaching hospital.

Material and methods

Between July 2012 and December 2014, seventeen cases of URSL for stones in a solitary kidney were reviewed. Patient demographics, stone dimensions, perioperative and post-operative outcomes were recorded in a prospectively maintained database. Serum creatinine levels pre-procedure and at follow-up were also compared.

Results

Seventeen cases of URSL were conducted with a mean age of 52.9 ±19.9 years. 8 of the 17 (47%) patients had stones in multiple locations and 13 (76%) were in the lower pole. The mean ± SD stone size and BMI were 13.0 ±8.9 mm and 31.6 ±5.8 kg/m², respectively. The stone free rate (SFR) was 82.5%. Fourteen (82.5%) patients were discharged the same day and 16 cases (94%) were discharged within 24 hours. For patients with deranged pre-operative serum creatinine, the mean serum creatinine level improved from 131.2 ±68.3 µmol/L pre-URSL to 106.5 ±36.7 µmol/L at follow-up. There was one Clavien grade II complication with a patient requiring additional antibiotics for post-operative urinary tract infection. There were no other major or minor complications.

Conclusions

Day case ureteroscopy for stone disease in a solitary kidney is safe and feasible with a low complication rate and an overall improvement in renal function.

Pediatric retrograde intra-renal surgery for renal stones <2 cm in solitary kidney

Introduction:

Management of renal stones in children with a solitary kidney is a challenge. In the current study, the efficacy and safety of retrograde intrarenal surgery (RIRS) in these children were determined.

Patients and Methods:

Records of children with renal stones who were treated at our institute between August 2011 and August 2014 were retrospectively assessed. Inclusion criteria were: Children with single renal stone <2 cm size, in a solitary kidney. A 7.5 Fr flexible ureteroscope (FURS) was introduced into the ureter over a hydrophilic guidewire under visual and fluoroscopic guidance - applying a back-loading technique. The stone was completely dusted using 200 μm laser fiber (0.2–0.8 joules power and 10–30 Hz frequency). At the end of the maneuver, a 5 Fr JJ stent was inserted into the ureter. The children were discharged home 24 h postoperative - provided that no complications were detected.

Results:

Fourteen children (3 girls and 11 boys) with median age 9.5 years (range 6–12) were included. The mean stone burden was 12.2 ± 1.5 mm (range 9–20). Stones were successfully accessed in all of the cases by the FURS except for 2 cases in whom a JJ stent was inserted into the ureter and left in place for 2 weeks to achieve passive dilatation. All of the stones were dusted completely. The immediate postoperative stone-free rate (SFR) was 79%, and the final SFR was 100% after 3 weeks. No intraoperative complications were observed.

Conclusions:

RIRS for renal stone <2 cm in children with a solitary kidney is a single-session procedure with a high SFR, low complication rate, and is a minimally invasive, natural orifice technique.

Current status of flexible ureteroscopy in urology

Retrograde intrarenal surgery (RIRS) is being performed for the surgical management of upper urinary tract pathology. With the development of surgical instruments with improved deflection mechanisms, visuality, and durability, the role of RIRS has expanded to the treatment of urinary calculi located in the upper urinary tract, which compensates for the shortcomings of shock wave lithotripsy and percutaneous nephrolithotomy. RIRS can be considered a conservative treatment of upper urinary tract urothelial cancer (UTUC) or for postoperative surveillance after radical treatment of UTUC under an intensive surveillance program. RIRS has a steep learning curve and various surgical techniques can be used. The choice of instruments during RIRS should be based on increased surgical efficiency, decreased complications, and improved cost-benefit ratio.

Retrograde intrarenal surgery for urinary stone disease in patients with solitary kidney: A retrospective analysis of the efficacy and safety

OBJECTIVES

To compare outcomes of retrograde intrarenal surgery for urolithiasis between patients with solitary kidneys and patients who have single-side urolithiasis with bilateral kidneys.

METHODS

We retrospectively analyzed outcomes of retrograde intrarenal surgery in solitary kidney patients (group A) carried out during 2007-2014, and in patients with bilateral kidneys with comparable stone burdens (group B). Stone-free status was defined as no residual fragment on computed tomography 1 month later.

RESULTS

There were 19 patients in group A (mean age 62.5 ± 18.4 years, range 14-76 years). The mean stone diameter and burden were 6.0 mm (range 3-24 mm) and 10.42 ± 6.92 mm, respectively. The stone-free rate was 94.7%, and no repeat procedure was required. The glomerular filtration rate tended to rise post-surgery (postoperative day 1: 48.67 ± 15.92 mL/min, 100.2%, P = 0.940; postoperative month 1: 51.32 ± 16.90 mL/min, 105.7%, P = 0.101) compared with preoperative rates. The stone-free rate and surgery time were not significantly different between the two groups, although post-surgical hospitalization time was longer for group A (4.05 vs 3.08 days, P = 0.037). The change in glomerular filtration rate was not significantly different between groups A and B (postoperative day 1: +0.101 vs +0.547 mL/min, respectively, P = 0.857; postoperative month 1: +2.749 vs 3.161 mL/min, respectively, P = 0.882). No significant difference was found in terms of complication rate.

CONCLUSIONS

Retrograde intrarenal surgery in solitary kidney patients is as safe and effective as in bilateral kidney patients.

Effect of urinary stone disease and its treatment on renal function

Urolithiasis is a common disease that affects urinary tract in all age groups. Both in adults and in children, stone size, location, renal anatomy, and other factors, can influence the success of treatment modalities. Recently, there has been a great advancement in technology for minimally invasive management of urinary stones. The epoch of open treatment modalities has passed and currently there are much less invasive treatment approaches, such as percutaneous nephrolithotomy, ureteroscopy, shockwave lithotripsy, and retrograde internal Surgery. Furthermore, advancement in imaging technics ensures substantial knowledge that permit physician to decide the most convenient treatment method for the patient. Thus, effective and rapid treatment of urinary tract stones is substantial for the preservation of the renal function. In this review, the effects of the treatment options for urinary stones on renal function have been reviewed.

Single-Stage Bilateral Versus Unilateral Retrograde Intrarenal Surgery for Management of Renal Stones: A Matched-Pair Analysis

PURPOSE

This study aimed to compare the effectiveness and safety of single-stage bilateral and unilateral retrograde intrarenal surgery (RIRS) for treatment of patients with renal stones.

PATIENTS AND METHODS

Patients undergoing single-stage bilateral RIRS for renal stones between January 2011 and April 2014 were retrospectively reviewed and matched to patients undergoing unilateral RIRS at a 1:1 ratio by the propensity score based on age, sex, body mass index, American Society of Anesthesiologists classification, stone burden, and stone location (involvement of the lower calix or not). Main outcome measures were stone-free rate per patient and per renal unit and RIRS-associated morbidity.

RESULTS

Of 60 patients treated by single-stage bilateral RIRS, 59 patients were matched with patients treated by unilateral RIRS. Stone-free rates per patient for bilateral RIRS and unilateral RIRS were 84.7% and 91.5%, respectively (P=0.255). Median operative time (100 vs 65 min, P<0.001) and postoperative hospitalization (2 vs 1 d, P=0.011) was significantly longer for bilateral RIRS than unilateral RIRS. Median changes in hematocrit (1.3% vs 1.0%, P=0.964) and serum creatinine level (3 vs 2 μmol/L, P=0.716) were similar between bilateral and unilateral RIRS. The overall complication rate was slightly higher with bilateral RIRS (11.9% vs 8.5%, P=0.542). No serious RIRS-associated morbidities occurred in either group.

CONCLUSION

Single-stage bilateral RIRS was as effective and safe as unilateral RIRS among propensity score-matched patients.