Surgical outcomes of patients who underwent retrograde intrarenal surgery using a ureteral access sheath to manage kidney stones sized 1-2 cm compared between patients who did and did not undergo preoperative ureteral stenting

The role of preoperative ureteral stenting in retrograde intrarenal surgery outcomes for renal stones: a matched-pair analysis

Introduction

Ureteral stenting is not routinely recommended, but it may be performed before or after retrograde intrarenal surgery (RIRS). We aimed to investigate the effect of preoperative ureteral stenting on the success rate and intraoperative, postoperative, and infectious complications in RIRS.

Material and methods

We retrospectively analysed the data of 581 patients who underwent RIRS. Demographic data, stone characteristics, presence of hydronephrosis, presence of congenital kidney anomaly and solitary kidney, duration of operation, and duration of hospitalisation were analysed. Intraoperative, postoperative, and infectious complications and the success rate of all operations were recorded. The patients were divided into 2 groups as prestented and non-prestented and matched in terms of age, sex, stone size, and number of stones. Ninety-four patients in the prestented group were matched with 282 patients in the non-prestented group with respect to age, sex, stone size, and number of stones (matched 1:3).

Results

The 2 groups were similar in terms of matching parameters and all other characteristics. After matching, the success rate was 77.7% (73/94) in the prestented group and 78% (220/282) in the non--prestented group, and there was no statistically significant difference between the 2 groups (p = 0.943). The intraoperative complication rate was statistically significantly higher in the non-prestented group (19.2% vs 28.7%, p = 0.046). Postoperative complications occurred in 22.3% of patients in the prestented group and 20.7% of patients in the non-prestented group (p = 0.429).

Conclusions

Preoperative ureteral stenting in RIRS was not associated with the success rate or postoperative and infectious complications. However, preoperative stenting was effective in decreasing only grade 1 intraoperative complications.

Safety and effectiveness of preoperative stenting compared to non-stenting in ureteroscopy for urinary stone disease: a meta-analysis of comparative studies

PURPOSE

Ureteroscopy (URS) is considered one of the first-line surgical treatments for urinary stones < 2 cm. Preoperative stenting (PS) employment in URS for urolithiasis remains debated, with evidence differing in terms of outcomes and recommendations. We sought to evaluate the influence of PS on surgical outcomes compared to non-PS (NPS) in patients with renal and ureteral stones undergoing ureteroscopic lithotripsy.

METHODS

Databases were searched until December 2023 for randomized and non-randomized studies reporting perioperative outcomes for PS and NPS. Pooled data were analyzed through a Random-Effects model when Higgins I2% heterogeneity values were > 50%; otherwise, a Fixed-Effects model was employed. Results were reported as risk ratios (RR), or mean differences (MD) with 95% confidence intervals (CI). Statistical significance was set at p < 0.05.

RESULTS

The analysis included 23,668 patients from 25 included studies (5 non-randomized prospective and 20 retrospective studies). Higher stone-free rates (SFR) were observed in kidney and ureteral stones (RR 1.05; 95%CI 1.03-1.08; p ≤ 0.0001), especially if managed with flexible URS (RR 1.05; 95%CI 1.01-1.09) in the PS cohort. Additionally, lower rates of intraoperative (RR 0.70; 95%CI 0.49-0.99; p = 0.04) and postoperative complications (RR 0.82; 95%CI 0.70-0.95; p = 0.008) were seen with PS. Both groups had a comparable operative time, length of stay (LOS), ureteral access sheath (UAS) placement success, and SFR in semi-rigid URS.

CONCLUSION

Higher SFR with PS were seen in kidney and ureteral stones, especially if f-URS was employed. Moreover, perioperative complications did not increase with PS. Future randomized studies, evaluating cost-effectiveness and quality of life are needed.

Predictive factors for difficult ureter in primary kidney stone patients before retrograde intrarenal surgery

Introduction

Ureter may be resistant to insertion of ureteral access sheath (UAS) and/or semi-rigid ureterorenoscope because of the narrow ureter, 'difficult ureter' especially in primary retrograde intrarenal surgery (RIRS) cases. We aimed to delineate the parameters that affect significantly the accessibility of the ipsilateral ureter of the stone-bearing patient side.

Material and methods

The data of age, gender, body mass index, comorbidities, prior urinary tract infection, prior stone passage, stone burden, stone density, number of stones, stone localization, surgery side, the presence of hydronephrosis and need for double J (DJ) stent due to difficult ureter for all patients were reviewed. Difficult ureter was defined as the insertion inability of a semi-rigid ureterorenoscope or UAS into the ureter at the surgery side. All patients were divided into two groups as difficult ureter group and non-difficult ureter group.

Results

A total of 454 patients who underwent RIRS for primary kidney stones were included. The incidence of difficult ureter was 7.5% (34/454). The patients in the difficult ureter group were younger. Female gender and prior urinary tract infection rates were higher in the difficult ureter group. Multivariate logistic regression analysis indicated that the factors significantly associated with higher odds of having a difficult ureter in primary RIRS patients were younger age (OR 1.040; 95% CI 1.010-1.070; p = 0.008), female gender (OR 2.859; 95% Cl 1.383-5.908; p = 0.005) and prior urinary tract infection (OR 3.327; 95% CI 1.230-8.999; p = 0.018).

Conclusions

Difficult ureter was associated with younger age at the time of RIRS, female gender and the manifestation of urinary infections in the patient's medical history.

Application of the direct in-scope suction technique in antegrade flexible ureteroscopic lithotripsy for the removal of a large ureteric calculus in a kidney transplant recipient: A case report

The occurrence of a large ureteric calculus in a transplanted kidney, originating from a donor, is a rare but significant complication. It poses risks such as urinary obstruction, septicemia, and potential loss of allograft function. In this case, we report our first use of the direct in-scope suction technique during antegrade flexible ureteroscopy lithotripsy. This method successfully removed a donor-derived ureteric calculus in a kidney transplant recipient. The procedure resulted in complete stone removal, and the patient experienced a favorable postoperative recovery without additional adverse events.

Flexible ureteroscopy for lower pole calculus: is it still a challenge?

PURPOSE

Flexible ureteroscopy (fURS) is steadily gaining popularity in the management of renal calculi, including those located in the lower pole (LP). Due to difficulty in accessing to the LP of kidney in minority of cases with fURS and reports of lower stone-free rate (SFR), it is still considered as a challenge in selected cases. The purpose of the review was to analyze the various aspects of fURS for LP stones.

METHODS

An extensive review of the recent literature was done including different factors such as anatomy, preoperative stenting, stone size, flexible scopes, types of lasers, laser fibers, suction, relocation, stone-free rates, and complications.

RESULTS

The significance of various lower pole anatomical measurements remain a subject of debate and requires standardization. Recent improvements in fURS such as single-use digital scopes with better vision and flexibility, high power laser, thulium fiber laser, smaller laser fiber, and accessories have significantly contributed to make flexible ureteroscopy  more effective and safer in the management of LP stone. The utilization of thulium fiber lasers in conjunction with various suction devices is being recognized and can significantly improve SFR.

CONCLUSIONS

With the significant advancement of various aspects of fURS, this treatment modality has shown remarkable efficacy and gaining widespread acceptance in management of LP kidney stones. These developments have made the fURS of LP stones less challenging.