Simultaneous Bilateral Endoscopic Manipulation for Bilateral Renal Stones

Propensity Score-Matched Analysis of Perioperative Outcomes of Supine versus Prone Percutaneous Nephrolithotomy

Objective: To compare the perioperative outcomes of supine and prone percutaneous nephrolithotomy (PCNL). Methods: A retrospective search of a tertiary medical center database yielded 517 patients who underwent supine (n = 91) or prone (n = 426) PCNL between September 2015 and July 2020. Data on demographics, baseline clinical parameters, and stone burden were included as predictors in a logistic regression model, generating a set of propensity scores. Seventy patients after supine PCNL were propensity score-matched 1:1 with patients after prone PCNL and compared for operative time, perioperative complications, system complexity, and stone-free rate. Results: We found that the operative time was significantly shorter in the supine PCNL group than in the prone PCNL group (85.5 ± 25.2 min vs. 96.4 ± 25.8 min, respectively; p = 0.012). The majority of both groups had low-grade (I-II) complexity systems (85.6% and 88.6%, respectively), with no significant difference among all grade groups (p = 0.749). There were no significant differences between the supine and prone PCNL groups in terms of the overall perioperative complication rate (8.6% vs. 4.3%, respectively; p = 0.301) or stone-free rate (74.3 vs. 65.7%, respectively; p = 0.356), while the rate of blood transfusion was significantly higher in the supine group (p = 0.023). Conclusions: In our study, we used propensity score matching to compare patients who underwent PCNL in the supine or prone position, adjusting for selection bias. Supine PCNL was associated with a shorter operative time but a higher blood transfusion rate, with no differences in the overall complication and stone-free rates.

Feasibility of Simultaneous Bilateral Endoscopic Surgery in Prone Split-Leg Position for Bilateral Upper Urinary Tract Calculi: A Pilot Study

INTRODUCTION

We explored the viability of simultaneous bilateral endoscopic surgery (SBES) in the prone split-leg position for managing bilateral calculi.

METHODS

We retrospectively reviewed 72 patients who underwent SBES, with procedures involving ureteroscopy (URS) and contralateral percutaneous nephrolithotomy (PNL) simultaneously, in prone split-leg position.

RESULTS

Operative times averaged 109.38 ± 30.76 min, with an average hospital stay of 7.79 ± 3.78 days. The bilateral stone-free rate (SFR) was 70.83%, while URS and PNL demonstrated comparable unilateral SFR (83.33% and 79.17%, respectively). Receiver operating characteristics curves for predicting unilateral residual fragments yielded an area under the curve of 0.84 (URS) and 0.81 (PNL) with respective cutoff values of stone diameter of 11.55 mm and 23.52 mm. Fifty-seven (79.17%) and 15 (20.83%) patients encountered grade 0-1/2 complications, with no severe complications (grade 3-5) recorded. No significant changes in blood count or renal function were observed post-SBES.

CONCLUSIONS

SBES in the prone split-leg position is a viable option for managing bilateral upper tract urolithiasis. Larger scale studies are needed to further assess safety and efficacy in various positions.

Efficacy of simultaneous bilateral surgery using the oblique overriding position in the treatment of bilateral kidney stones

To compare the safety and the efficacy of simultaneous bilateral surgery in the oblique overriding position versus staging surgery in the treatment of bilateral renal calculi. A total of 46 patients with bilateral renal stones from May 2019 to January 2022 in our center were retrospectively analyzed, including 29 males and 17 females, with a mean age of 48 ± 13.6 years, body mass index of 24.6 ± 2.3 kg/m2, and uneven size of bilateral renal stones, with a mean diameter of 29.5 ± 9.1 mm on the side with the larger kidney stones (PCNL) and a mean diameter of 13.1 ± 3.2 mm on the side with the smaller kidney stones. The patients were divided into two groups for simultaneous and stepwise bilateral endoscopic surgery, and the operative time, anesthesia time, postoperative hemoglobin, blood creatinine, postoperative VAS pain score, Clavien complication rating, average hospital stay, and stone removal rate at one month after surgery were evaluated in both groups. The simultaneous group outperformed the other group in anesthesia time, operative time, VAS score, and mean number of days in the hospital, and there were no significant differences between the two groups in postoperative hemoglobin drop values, hematocrit elevation values, Clavien complication ratings, and stone clearance rate at one month. Both simultaneous surgery and staging surgery were safe and effective. Simultaneous surgery can effectively shorten the operation and anesthesia time, and reduce the postoperative pain and hospital days of patients while ensuring similar stone clearance rates.

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.

Should we treat asymptomatic concurrent contralateral renal stones? A longitudinal analysis

The objective is to explore the need for future surgery among patients treated for asymptomatic concurrent contralateral stones versus those that were not. Upon IRB approval, we retrospectively reviewed records of patients who underwent stone surgeries (SWL, URS, PCNL) from 2009 to 2018. Patients were included if they were greater than 18 years old, had a minimum follow-up of 2 years, and had pre-operative imaging. Patients were divided into three groups: bilateral surgery, ipsilateral surgery with, and without asymptomatic concurrent contralateral stones. Cox regression was used to analyze patients' need for future surgery while controlling demographic and comorbid characteristics. Of the 1666 patients included, 51.9% were men. They were 59.7 ± 15 years and had a BMI of 31.3 ± 8.2 kg/m². During the follow-up of 5.2 ± 2.2 years (range 2-11 years), patients who had bilateral surgery and patients who had ipsilateral surgery without treatment of the asymptomatic concurrent contralateral stones had no difference in the need for future surgery (41.7% vs. 43%, p = 0.585). When stratified by stone size, patients with contralateral stones > 6 mm were more likely to require future surgical treatment than those treated bilaterally (p < 0.001). Our study demonstrates that treating asymptomatic concurrent contralateral stones does not lower the need for future surgical interventions. However, asymptomatic concurrent contralateral stones > 6 mm may portend earlier need for treatment. Therefore, bilateral treatment should be considered at presentation.

Simultaneous bilateral endoscopic surgery in a pediatric patient: Description of a NOVEL technique

INTRODUCTION

Simultaneous bilateral endoscopic surgery (SBES) is the performance of a percutaneous nephrolithotomy (PCNL) on one side and a retrograde intrarenal surgery (RIRS) on the other kidney simultaneously.

OBJECTIVE

Our aim is to report through a video the surgical technique and the step-by-step details of a SBES performed in a pediatric patient.

PATIENTS AND METHODS

A 12-year-old male patient with bilateral upper tract urolithiasis.

RESULTS

Supine PCNL is performed in Galdakao-modified Valdivia position. Ureteroscopic surgeon performs retrograde pyelography on PCNL kidney. Percutaneous access under fluoroscopic guidance trough the lower calyx and dilated with Amplatz dilators to 17.5 Fr. Storz® 17.5 MIP Nephroscope is introduced and fragmentation with pneumatic lithotripter starts. On the other kidney, after introduction of ureteral sheet 12/14 Fr and digital flexible ureteroscope Flex Xc ® 9.5Fr, pulverization of the stone starts with Laser Holmium YAG (Oddysey®). Surgeons work simultaneously and share fluoro-scopic c-arm.

CONCLUSION

SBES can be reproduced in children. Proper planification and preparation of the involved team and OR set up are essential. Further prospective randomized studies are needed to establish safety and efficacy of SBES in pediatric patients.

[Clinical outcomes of simultaneous bilateral endoscopic surgery for bilateral upper urinary tract calculi]

OBJECTIVE

To discuss the efficacy and safety of simultaneous bilateral endoscopic surgery (SBES) for bilateral upper urinary tract calculi, and to summarize the initial experience.

METHODS

Patients diagnosed with bilateral upper urinary tract calculi who underwent SBES in the Department of Urology, Beijing Chao-Yang Hospital from January 2019 to January 2020 were enrolled retrospectively. The demographic and clinical data of the patients were recorded, and the operation status, stone free rate (SFR) and peri-operative complications were analyzed. The primary end point was SFR, and second end point was peri-operative complications.

RESULTS

A total of 23 patients underwent SBES, of which SBES was completed in 19 patients (12 males, and 7 females). The mean age was (41.3±12.0) years. Fourteen patients underwent modified supine position surgery and 4 patients in prone split-leg position. There was no statistical difference in the demographic and baseline clinical data of the patients in different positions. One patient underwent right percutaneous nephrolithotomy (PCNL) and left endoscopic combined intra-renal surgery (ECIRS) in the prone split-leg position, while 18 patients received simul-taneous surgery with PCNL and contralateral retrograde intra-renal surgery (RIRS). The mean anesthesia and operation time was (128.7±26.5) min and (70.7±20.3) min, respectively, which was significantly longer in the patients with prone split-leg position than in the patients with modified supine position, anesthesia time in the patients with prone split-leg position and modified supine position: (148.4±20.4) min vs. (121.6±25.3) min, respectively, t=－2.121, P=0.049, while the operation time in the patients with prone split-leg position and modified supine position: (86.4±21.1) min vs. (65.1±17.4) min, respectively, t=－2.222, P=0.040. There was no significant difference between the two groups in indwelling of nephrostomy [prone split-leg position and modified supine position: (2.6±0.9) d vs. (2.1±1.0) d, respectively; t=－0.880, P=0.391] and the length of hospital stay [prone split-leg position and modified supine position: (6.0±2.7) d vs. (5.2±1.8) d, respectively; t=－0.731, P=0.475]. One month after the operation, the SFR was 78.9%, and 3 patients had minor peri-operative complications (Clavien-Dindo grades Ⅰ/Ⅱ) without any serious complications (Clavien-Dindo grades Ⅲ/Ⅳ/Ⅴ).

CONCLUSION

The simultaneous bilateral endoscopic surgery would decrease the operation time and anesthesia exposure under the premise of ensuring the SFR, which is helpful to reduce the risk of peri-operative complications, especially to the patients who can not tolerate the second-stage or long-time operation.

Simultaneous and synchronous bilateral endoscopic treatment of urolithiasis: a multicentric study

Introduction

The general prevalence of bilateral urolithiasis has risen to 15% and bilateral non-simultaneous treatment has been reported to have good outcomes. The objective of this study was to evaluate the effectiveness and safety of simultaneous bilateral endoscopic surgery (SBES).

Material and methods

An international multicenter analysis was performed between May 2015 and December 2017. All patients with bilateral stone disease that underwent SBES were included. Patients were treated under general anesthesia in either the supine or lithotomy position. Demographic, clinical, intraoperative and postoperative data were analyzed.

Results

A total of 47 patients were included. Mean age was 53.8 years and 70% of the patients were males. The mean American Society of Anesthesiology (ASA) score was 2. The mean diameter of right- and left-sided stones was 29.43 mm (2–83 mm) and 31.15 (4–102 mm), respectively. Staghorn stones were treated in 18 cases (8 right-sided and 10 left-sided), four of them were defined as complete staghorn. The procedures performed were 42 cases of bilateral URS and PCNL and ureteroscopy. Additionally, 5 bilateral flexible ureteroscopy (fURS) cases were described. Intraoperative complications occurred in five patients: four of them were classified as Clavien-Dindo (CD) I and one as CD II. Postoperatively, there were two cases with CD I, 6 with CD II and one CD IIIa.

The stone-free status was 70%. Residual stones (30%) were detected only on the side treated for high-volume (complete) staghorn calculi.

Conclusions

SBES is a feasible, effective and safe procedure. It may potentially avoid repeated anesthetic sessions as needed for staged procedures and reduce the length of patients' hospital stay.

Comparison of supine and prone miniaturized percutaneous nephrolithotomy in the treatment of lower pole, middle pole and renal pelvic stones: A matched pair analysis

Purpose

We aimed to compare the outcomes of supine and prone miniaturized percutaneous nephrolithotomy (m-PNL) in the treatment of lower pole, middle pole and renal pelvic stones.

Materials and Methods

54 patients who performed supine m-PNL between January 2017 and March 2018 and 498 patients who performed prone m-PNL between April 2015 and January 2018 were included in the study. Of the 498 patients, 108 matching 1: 2 in terms of age, gender, body mass index, American Association of Anesthesiology score, stone size, stone localization and hydronephrosis according to the supine m-PNL group were selected as prone m-PNL group. The patients with solitary kidney, upper pole stone, urinary system anomaly or skeletal malformation and pediatric patients (<18 years old) were excluded from the study. The success was defined as ‘complete stone clearance’ and was determined according to the 1^st month computed tomography.

Results

The operation time and fluoroscopy time in supine m-PNL was significantly shorter than prone m-PNL group (58.1±45.9 vs. 80.1±40.0 min and 3.0±1.7 min vs. 4.9±4.5 min, p=0.025 and p=0.01, respectively). When post-operative complications were compared according to the modified Clavien-Dindo classification, overall and subgroup complication rates were comparable between groups. There was no significant difference between the groups in terms of the success rates (supine m-PNL; 72.2%, prone m-PNL; 71.3%, p=0.902).

Conclusions

Supine m-PNL procedure is more advantageous in terms of operation time and fluoroscopy time in the treatment of lower pole, middle pole and renal pelvic stones.

Supine versus prone position for percutaneous nephrolithotripsy: A meta-analysis of randomized controlled trials

OBJECTIVE

To compare the safety and efficacy of percutaneous nephrolithotripsy (PCNL) in supine versus prone position for patients with renal or upper ureteral calculi.

METHODS

A systematic search of Pubmed, Embase and Cochrane Central Register of Controlled Trials was performed to identify all eligible studies. All included randomized controlled trials (RCTs) were evaluated based on the inclusion and exclusion criteria. After quality assessment and date extraction, a meta-analysis was performed using RevMan 5.3 software.

RESULTS

A total of 15 RCTs with 1474 patients were included in our meta-analysis. Pooled data showed that PCNL in supine position could significantly reduce the operative time [weighted mean difference (WMD) -12.02, 95% confidence interval (CI) -20.49 to -3.54, p = 0.005] and rate of fever [risk ratio (RR) 0.67, 95% CI 0.46 to 0.97, p = 0.03] compared to prone position. In addition, no significant differences could be found between groups in stone-free rate (p = 0.31), hospital stay (p = 0.59) and rate of overall complications (p = 0.11), mainly including urinary leakage (p = 0.83), pleural effusion (p = 0.74) and blood transfusion (p = 0.58).

CONCLUSIONS

The current study found comparable stone-free rate and significant lower rate of postoperative fever in supine PCNL compared with prone PCNL. PCNL in supine position could be a safe and efficient choice for patients with renal or upper ureteral calculi.

Simultaneous bilateral percutaneous nephrolithotomy: Effectiveness and safety

OBJECTIVES

To evaluate the effectiveness and safety of simultaneous bilateral percutaneous nephrolithotomy performed in patients affected with bilateral renal calculi.

MATERIALS AND METHODS

This is a prospective study from September 2012 to November 2016. Patients diagnosed of bilateral kidney stones with abdominal CT scan were included. Surgical technique prone position, renal puncture guided by fluoroscopy and tract dilation up to 24Ch. We reviewed demographic and stone characteristics, stone free rate, clinical success, complications and follow-up.

RESULTS

During the study period, 732 percutaneous nephrolithotomies were performed. Eighteen patients were included (36 renal units, 2.5%), 13 men and 5 women, with a median age of 58 years and an interquartile range (IQR) of 40-66. Median stone burden was 228mm² (IQR 134-389); median operative time, 150minutes (IQR 97-180); and median hospital stay, 5 days (IQR 5-15). Stone free rate was 80%. Residual calculi were encountered in 8 renal units (22.2%) and required other complementary techniques for their complete tesolution 4 external shockwave lithotripsies, one open ureterolithotomy, 2 ureteroscopies and one second look. Major complications included 4 cases of severe hemorrhage managed with angiographic embolization. The median follow-up was 36 months (range 26-46).

CONCLUSIONS

Simultaneous bilateral percutaneous nephrolithotomy is an effective and safe procedure in patients affected with bilateral renal calculi. It is a surgical challenge that should be performed in selected patients and in centers with experience.

Bilateral Same-Session Ureteroscopy for Treatment of Ureteral Calculi: A Systematic Review and Meta-Analysis

INTRODUCTION

The traditional procedure for the management of bilateral ureteral stones is staged ureteroscopic lithotripsy (URS). However, in recent years particularly, some urologists advocate same-session bilateral URS on the ground of success rates and minimal morbidity. This systematic review is to evaluate the efficacy and safety of same-session bilateral ureteroscopy for the treatment of ureteral calculi.

MATERIALS AND METHODS

We conducted a bibliographic search using MEDLINE (1980 to August 2015) and EMBASE (1980 to August 2015). Review articles and abstract data were excluded and only studies in English reporting on outcomes of bilateral URS were included in this meta-analysis. Two reviewers independently assessed the quality of each included studies and extracted data. STATA 12.0 was used for meta-analysis.

RESULTS

In 11 studies, 431 patients were reportedly treated with bilateral URS. Most of the stone sizes were not larger than 20 mm. The mean stone-free rate is 96% for the distal ureter, 85% for the middle ureter, and 72% for the proximal ureter. The mean operative time ranged from 45 to 100 minutes with an average hospital stay from 2 to 4 days. The overall complications rates were 17%, with the incidence of postoperative fever 4%, postoperative pain 20%, and gross hematuria 4%. Other complications, including urosepsis, urinary tract infection, small mucosal laceration, stone migration, and ureteral perforation, accounted for 6% of overall complications.

CONCLUSIONS

This meta-analysis found that bilateral same-session ureteroscopy could achieve a high overall stone-free rate. There might be a relatively higher complication incidence, but most of the complications are minor. For selected cases, bilateral URS could be safe and effective.