RETROGRADE URETEROPYELOSCOPIC TREATMENT OF 2 CM. OR GREATER UPPER URINARY TRACT AND MINOR STAGHORN CALCULI

Stone dust in endourology: a systematic review of its definition, management, and clinical impact

OBJECTIVE

To evaluate and synthesise the existing literature on stone dust (DUST) in endourology, focusing on its definition, creation methods, and removal techniques.

METHODS

A comprehensive electronic literature search was conducted using the PubMed/Medline, Web Of Science, and Embase databases to identify reports published until October 2024. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The outcomes assessed included the definition of DUST, the method by which DUST was created, and how it was removed, evaluating both in vitro and in vivo studies. The review also assessed the efficacy of different laser technologies, including holmium-yttrium-aluminium-garnet (Ho:YAG) laser, thulium fibre laser (TFL), and pulsed thulium-YAG laser (p-Tm:YAG) laser, in generating DUST and their clinical relevance in stone management.

RESULTS

The systematic review identified 43 eligible studies, revealing significant variability in the definition and evaluation of DUST. Criteria for DUST ranged from sub-millimetre particle sizes to functional properties like floatability and aspiration capability. While Ho:YAG lasers remain widely used for stone dusting, emerging technologies such as TFL and p-Tm:YAG lasers have shown superior efficiency in producing finer particles and reducing retropulsion. No consensus emerged regarding the settings used by surgeons and the pre-settings provided by laser manufacturers.

CONCLUSIONS

Despite the widespread use of dusting techniques in endourology, a standardised definition of DUST remains lacking, with significant variability in laser settings, particle sizes, and evacuation methods. It must be clarified whether DUST should be defined as a noun-representing a distinct entity with a precise definition-or as the result of the dusting process, in which case clear criteria are needed to characterise it accurately. Establishing standardised definitions and protocols through international consensus is crucial to optimising clinical outcomes and ensuring consistency in future research.

Is fluoroscopy-free single-use flexible ureteroscopy a feasible treatment for kidney stones with abnormal renal anatomy?

Objective

This study aimed to evaluate the feasibility of the fluoroscopy-free single-use flexible ureteroscopy procedure in the treatment of kidney stones with abnormal renal anatomy compared to normal renal anatomy.

Methods

Forty patients with abnormal (Group A) and 80 patients with normal (Group B) renal anatomy who had 10-20 mm renal stones were included. They were treated with LithoVue single-use flexible ureteroscopy (Boston Scientific, Marlborough, MA, USA) after ureteric dilatation by two different size semi-rigid ureteroscopes. This technique was chosen as the aim was to exclude any ureteric pathology (e.g., stone or stricture), confirm the placement of a safe guidewire, avoid balloon dilatation of the ureter, and achieve safe insertion of a 12 Fr, 35/45 cm ureteric access sheath with optical and tactile sign and without fluoroscopy image for guidance.

Results

The mean ages were 43 years and 45 years in Group A and Group B, respectively. The mean stone burden was 14.62 (standard deviation: 5.35) mm3 and 14.79 (standard deviation: 4.58) mm3 in Group A and Group B, respectively. There is no significant difference between both groups according to the mean operative time, hospital stay, or stone-free rate. The stone-free rate was about 93% in both groups when the stone size was between 10 mm and 15 mm, and less than 54% when the stone size was more than 15 mm to 20 mm. In the majority of cases (80.0% in Group A and 92.5% in Group B), we completed the procedure without fluoroscopy. The perioperative complication rates were comparable in the two groups.

Conclusion

Fluoroscopy-free single-use flexible ureteroscopy, when performed by expert urologists, is a feasible treatment for pre-stented patients with kidney calculi of ≤15 mm with abnormal renal anatomy.

Percutaneous nephrolithotomy or flexible ureteral lithotripsy, which one is better for patients with upper ureteral calculi of 1.5-2.0 cm in diameter

PURPOSE

First research to evaluate the clinical efficacy and safety of flexible ureteral lithotripsy (FURSL) and percutaneous nephrolithotomy (PCNL) in the treatment of the upper ureteral stone is between 1.5 cm and 2.0 cm in diameter since there is no consensus with such ureteral stone yet.

METHODS

From December 2018 to October 2022, 104 patients with calculi in the upper ureter received percutaneous nephrolithotomy (PCNL)or flexible ureteroscopic lithotripsy (FURSL) in our institution. The clinical data of the patients in the two groups were retrospectively searched. Stone removal rate, operation time, blood loss, postoperative pain score, postoperative inflammatory factor, postoperative complication rates and ureteral obstruction three months after the operation were compared between the two groups.

RESULTS

A total of 104 patients were included in the study. The stone clearance rate and the secondary surgery rate were 88.89% and 7.41% in the FURSL group, the figures were 97.96% and 2.0% in the PCNL group (p = 0.067, 0.497). Regarding ureteral obstruction three months after the operation, there were 2 patients in FURSL group and 0 patients in PCNL group(p = 0.497).Compared to patients in FURSL group, patients in the PCNL group had shorter operation time(PCNL 71.81 ± 18.94 min vs. FURSL 86.80 ± 22.49 min, p = 0.0004), fewer complications(PCNL 20.37% vs. FURSL 6.12%), and lower postoperative inflammatory factor(p = 0.0004), yet they got more hemoglobin drop (PCNL 13.14 ± 9.81 g/L vs. FURSL 4.77 ± 3.55 g/L, p < 0.0001), higher postoperative pain scores(p = 0.0017) in the first three postoperative days and longer hospital stay (PCNL 4.96 ± 1.21 days vs. FURSL 3.60 ± 0.83 days).

CONCLUSION

Both FURSL and PCNL were effective methods for treating upper ureteral stones of 1.5-2.0 cm in diameter given the extremely high stone clearance rate and a very low secondary surgery rate, as long as rare ureteral obstruction in medium-long term observation. Additionally, FURSL can effectively reduce surgical bleeding, postoperative pain, and hospital stay, while PCNL can decrease operation time, the risk of infection, and complications. Therefore, doctors could select suitable surgical treatment for those patients depending on their different clinical situations based on these findings.

Analyzing global research trends and focal points in the utilization of laser techniques for the treatment of urolithiasis from 1978 to 2022: visualization and bibliometric analysis

Laser lithotripsy is gaining global prominence and is a dynamically progressing field marked by a continual influx of new and comprehensive research each year. Recently, there has been a noticeable shift toward the adoption of various kinds of lasers, such as holmium: yttrium-aluminum-garnet (Ho:YAG) and thulium fiber (TFL) lasers. Consequently, we aim to conduct a bibliometric analysis to analyze key areas of research activity within scientific publications that center on the utilization of laser techniques in urolithiasis. A search of the literature spanning from 1978 to 2022 was carried out on 25 December 2023 using the Scopus database to explore research related to the application of laser techniques for urolithiasis treatment. Visualization analysis was performed using VOSviewer software (version 1.6.20). We examined 962 publications that met the specified criteria, 791 (82.22%) of which were original articles. The analysis of the retrieved publications indicated a consistent increase in research output from 1978 to 2022; a particularly noteworthy surge occurred after 2003. In particular, the U.S. claimed the leading position as the most productive country, contributing 211 articles (21.93%). However, India had the highest research productivity according to the adjustment index of 19.08. In the European region, 324 publications (33.68% of the total) originated from 25 countries. The Journal of Endourology contributed the most between 1978 and 2022 (n = 96, 9.98%). The most cited paper examined the effectiveness of holmium: yttrium-aluminum-garnet (Ho:YAG) lasers, while a subsequent study focused on the use of a thulium fiber laser (TFL), an emerging laser technology that has gained increased recognition. Co-occurrence analysis revealed three distinct clusters focusing on the types of laser technology, minimally invasive approaches, and success rate/postoperative complications. This comprehensive investigation delves into the global landscape of laser use for the treatment of urolithiasis. This review supports the emerging clinical concept of using various types of laser technology for urolithiasis treatment. Moreover, the hot issues that researchers should focus on based on the findings of this study are the use of different types of laser lithotripsy in view of the surgical approach, success rate and complications.

To Evaluate the Impact of Ho:YAG Laser Lithotripsy for Ureteroscopic Removal of Proximal and Distal Ureter Calculi

Background Urinary calculus illness is a prevalent clinical issue encountered by the medical community, particularly urologists, in contemporary society. Laser technologies have been widely accepted as standard modalities for lithotripsy applications. Using the Ho:YAG laser has expanded the range of applications for ureteroscopic stone management (URS), enabling the treatment of bigger stones in all regions of the upper urinary tract. It is noteworthy that ureteroscopy (URS) demonstrates superior rates of stone clearance for distal stones, regardless of their size, with a success rate of 94.5% compared to 74% for other treatment modalities. Significant variation exists in the reported results and problems associated with Ho:YAG laser lithotripsy across different trials, as documented in the literature. The procedure's outcome might vary based on factors such as the size of the stone, the length of impaction, the presence of ureteral damage and granulation, the kind and size of endoscopes used, and the specific energy settings employed by various operators. The present study aimed to evaluate the impact of Ho:YAG laser lithotripsy for ureteroscopic removal of proximal and distal ureter calculi. Methods This prospective observational study was carried out in the Department of Urology at DY Patil Medical College and Hospital, Pune, from March 2021 to March 2023. Patients diagnosed with a case of ureteric stone who opted for URSL during the study period were included. A total of 50 patients who underwent URSL in the urology department were included in this study. These were then grouped into those with proximal ureteral stones and distal ureteral stones. (25 each) Results The study observed that patients diagnosed with proximal ureteral stones had bigger calculi, with a mean stone size of 15mm, in comparison to patients with distal ureteral stones, with a mean stone size of 10mm (P=0.010). The stone burden was significantly higher for proximal ureteral stone patients than those with distal ureteric stones (P=0.010). The average duration of the operating procedure for upper ureter stones was 70 minutes, but for lower stones, the mean operative time was 45 minutes (P<0.001). No statistical significance was seen in the median age of patients between the two groups (P=0.89). The maximum number of cases in the upper stone group were in the age group of 16-30 years, and in the lower stone group was in the age group of 31-45 years. The prevalence of DJ stents at the time of presentation was higher among patients diagnosed with proximal ureteric stones than those with distal ureteric stones, with rates of 28% and 20%, respectively (P=0.508). Full fragmentation was successfully accomplished in all patients within the distal calculus group, accounting for 100% of the cases. At the same time, for proximal ureteric stones, a single laser lithotripsy session resulted in 92% (23 patients) achieving a stone-free status after two weeks.  Conclusion The study observed that stone size, burden, and procedure duration were statistically significant among other criteria. Mean age, stone HU, prior DJ stent, and stone-free rate were statistically insignificant. The procedure indicated that Ho:YAG laser lithotripsy has efficacy in treating both proximal and distal ureteral stones, with minimal intraoperative and postoperative complications. None of the complications were due to laser energy.

The outcomes of flexible ureteroscopy for renal calculi of 2 cm or more with and without the use of ureteral access sheath: A retrospective study

INTRODUCTION

The rate of success of retrograde intrarenal surgery (RIRS) for treating urinary tract stones is high, and the procedure is growing in popularity. The routine use of ureteral access sheath (UAS) remains somewhat controversial. The aim of this study was to assess the efficacy and safety of employing UAS during flexible ureteroscopy for treating renal stones ≥ 2 cm.

METHODS

This retrospective study was accomplished from January 2021 to February 2023. From 495 consecutives flexible ureteroscopies, 112 patients had renal stones ≥ 2 cm (60 patients with the use of UAS and 52 patients without). The stone-free status was verified after 8 weeks of operation.

RESULTS

The average diameter of the renal stones in non-UAS or UAS treated groups was 22.5 mm and 22.6, respectively. None of the groups differed significantly in terms of stone side, stone size, stone position, or Hounsfield unite but there was significant difference (p < 0.001) among two groups as regard pre-operative stenting (cases with UAS had 23.3% pre-operative stenting).

CONCLUSIONS

It is not always necessary to use UAS in conjunction with flexible ureteroscopy and laser lithotripsy to treat renal calculi bigger than or equal two cm. Without the assistance of UAS, the surgery may be carried out successfully and safely.

Ex vivo study: is it possible to overcome the blurriness caused by holmium laser fragmentation of kidney stones?

Better endoscopic vision is mandatory for successful ureteroscopic stone operations to achieve shorter operating time. However, an important impairing factor for a good endoscopic view is the cloudiness of vision which was formed during laser fragmentation. Holmium laser fragmentation of calcium oxalate stones produces calcium carbonate solubility of which is dependent on pH, citrate, and phosphate. In this ex vivo research, the solubility of calcium carbonate has been investigated in solutions composed of various concentrations of citrate and phosphate buffered at different pH levels after laser fragmentation of calcium oxalate stones. Calcium oxalate stones were placed into the laboratory tubes filled with various concentrations of citrate-phosphate buffers with different pH values. Laser energy in dusting mode was applied to the stones and spectrophotometric measurement for optical density (OD) was calculated for each buffered solution for clarity comparison. In the first phase, solutions composed of four different molar concentrations of citrate-phosphate buffer (0.2, 0.3, 0.4 and 0.5 molars) at various pH levels were used. Then, the next phase of the study was designed to compare solutions demonstrating the lowest OD values with an isotonic saline solution. The results were most convenient at 0.5 molarity (pH = 6) followed by 0.4 molarity (pH = 7) in the first phase (OD values of 0.054 and 0.065, respectively). In the next phase, OD values of both buffered solutions were significantly lower than those of isotonic saline solution (p = 0). Two specific buffers have provided better optic visibility values after laser fragmentation supporting their use as an irrigation solution for the favor of less cloudiness.

Retrograde intrarenal surgery: Past, present, and future

With the recent technological advancements in endourology, retrograde intrarenal surgery has become a more popular procedure for treatment of urolithiasis. Furthermore, since the introduction of new laser systems and advanced flexible ureteroscopy with miniaturized ureteroscopes, the treatment indications for retrograde intrarenal surgery have expanded to include not only larger renal stones of >2 cm but also upper urinary tract urothelial carcinoma, ureteral stricture, and idiopathic renal hematuria. Clinicians must keep up with these trends and make good use of these technologies in the rapidly changing field of endourology. Simultaneously, we must consider the risk of various complications including thermal injury due to laser use, ureteral injury caused by the ureteral access sheath, and radiation exposure during retrograde intrarenal surgery with fluoroscopic guidance. This review focuses on the past, present, and future of retrograde intrarenal surgery and provides many topics and clinical options for urologists to consider.

Flexible ureteroscopy and laser lithotripsy for renal stones 2 cm or greater: A single institutional experience

With improvements in endoscopy and laser technology, flexible ureteroscopy (FURS) has been a viable treatment option for large renal stones. Here, we share our experience of the FURS treatment for renal stones 2 cm or greater.We evaluated 251 consecutive patients who underwent FURS and holmium laser lithotripsy for renal stones 2 cm or greater between January 2015 and April 2019. Stone size was defined as the longest axis on non-contrast computed tomography. Data were retrospectively collected from electronic medical records. Patient demographics, stone clearance rates and perioperative complications were evaluated.There were 165 male patients and 86 female patients with an average age of 46.9 years (range 22-80 years). Mean stone size was 2.7 cm and the average number of procedures was 1.4 (range 1-5). The stone-free rate at the end of the first, second and third procedure was 61.9%, 82.9%, and 89.5%, respectively. The final stone-free rate decreased as stone size grows, and it was only 58.3% for kidney stones larger than 4 cm after an average of 2.3 procedures. The lowest clearance rates were observed in lower calyx calculi (87.2%) and multiple calyx calculi (83.5%). The overall complication rate was 15.1%, and the most common complication was postoperative fever (9.6%). One patient required blood transfusion, owing to postoperative coagulation disorders induced by urosepsis.Single or staged FURS is a practical treatment option for the renal stones sized 2 to 4 cm with acceptable efficacy and safety. Stone clearance rate of FURS treatment is mainly affected by stone size and location.

RIRS with Vacuum-Assisted Ureteral Access Sheath versus MPCNL for the Treatment of 2-4 cm Renal Stone

OBJECTIVE

Comparison of outcomes between RIRS with vacuum-assisted ureteral access sheath (V-UAS) and MPCNL in the treatment of renal stone.

MATERIALS AND METHODS

28 patients with 2-4 cm renal stone were treated using RIRS with 14/16 F V-UAS. The outcomes were compared to those who underwent MPCNL with 16 F Amplatz sheath using a matched-pair analysis in a 1 : 2 scenario. Matching criteria included stone size, location and laterality, gender, age, BMI, and degree of hydronephrosis. Patients' demographics, perioperative and postoperative characteristics, complications, stone-free rate (SFR), and auxiliary procedures were compared.

RESULTS

Mean operative times for the RIRS and MPCNL groups were 72.4 ± 21.3 minutes and 67.4 ± 25 minutes (P = 0.042). Postoperative pain was significantly less in the RIRS group. The initial SFR was 50% for the RIRS group and 73.2% for the MPCNL group (P = 0.035). The final SFR at postoperative three months improved to 89.3% for the RIRS group and 92.9% for the MPCNL group (P = 0.681). The auxiliary procedure rates were higher in the RIRS group (42.9% vs. 25%, P = 0.095). The overall complication rate in the RIRS group was lower, but the significant difference was not found.

CONCLUSION

In the treatment of 2-4 cm renal stone, using V-UAS in RIRS can improve surgical efficiency with lower postoperative early pain scores. Comparing with MPCNL, its initial SFR was more depressed, and there is still a trend towards requiring more auxiliary procedures to achieve comparable final SFR.

The role of ureteroscopy for treatment of staghorn calculi: A systematic review

Objective

To define the role of ureteroscopy for treatment of staghorn calculi.

Methods

A systematic review was conducted using the Scopus and Medline databases. Original articles and systematic reviews were selected according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies relating to the role of ureteroscopy for treatment of staghorn calculi were included.

Results

In five studies on ureteroscopic monotherapy, stone-free rate (SFR) ranged from 33% to 93%, with a maximum four ureteroscopy sessions per patient and no major complications. Endoscopic combined intrarenal surgery (ECIRS) was compared with percutaneous nephrolithotomy (PNL) in two studies and reached significantly higher SFR (88%-91% vs. 59%-65%) and lower operative times (84-110 min vs. 105-129 min). The role of salvage ureteroscopy for residual stones after primary PNL has been highlighted by two studies with a final SFR of 83%-89%. One study reported on the feasibility of ureteroscopy for ureteral stones and same-session PNL for contralateral staghorn calculi, with a SFR of 92%.

Conclusion

Ureteroscopy plays a pivotal role in the setting of a combined approach to staghorn calculi. Ureteroscopy is also particularly suitable for clearance of residual stones. In specific cases, ureteroscopy may become the sole applicable therapeutic option to staghorn calculi. Technological advances and refinement of techniques suggest a major role of ureteroscopy for staghorn calculi treatment in close future.

Percutaneous nephrolithotomy versus flexible ureteroscopy in terms of cost-effectiveness in patients with 10-30 mm renal stones

PURPOSE

Kidney stones are one of the most common urological problems. When deciding on the method of treatment for this common disease, the cost of the procedure should also be taken into consideration.

MATERIALS AND METHODS

We performed a retrospective analysis of 55 patients who underwent percutaneous nephrolithotomy and 75 patients who underwent retrograde intrarenal surgery between January 2016 and November 2018. Until operative success was achieved, all additional surgical procedures, extracorporeal shock wave lithotripsy procedures, and interventional procedures required to resolve complications were recorded. Total cost was compared between the percutaneous nephrolithotomy and retrograde intrarenal surgery groups.

RESULTS

No significant difference was found between the percutaneous nephrolithotomy and retrograde intrarenal surgery groups in terms of gender, mean age, stone side, stone localization and stone surface area. The total cost of 55 patients that underwent percutaneous nephrolithotomy was calculated as US$14.766 after the first operation, and the total cost of 75 patients that underwent retrograde intrarenal surgery was determined to be US$46.627. The mean cost per patient was calculated US$320 ± US$186 for percutaneous nephrolithotomy and US$749 ± US$242 for retrograde intrarenal surgery (p < 0.001).

CONCLUSIONS

Percutaneous nephrolithotomy is a lower-cost and successful method in the surgical treatment of 1-3 cm stones, but the serious complications involved in this operation should be kept in mind.

Comparison between retrograde intrarenal surgery and percutaneous nephrolithotripsy in the management of renal stones: A meta-analysis

Percutaneous nephrolithotripsy (PCNL) is recommended as the first-line treatment for the management of kidney stones that are ≥2 cm in diameter. Retrograde intrarenal surgery (RIRS) has become increasingly preferred due to its high level of safety and repeatability, particularly in small stones. However, whether PCNL has superior efficacy and lower complication rates when compared with RIRS remains controversial. Therefore, the present meta-analysis was conducted to compare the clinical outcomes of patients treated with PCNL and RIRS as therapy for renal stones. Clinical trials published in PubMed, Web of Science, Excerpta Medica dataBASE (EMBASE), and the Chinese Biomedical Database (CBM) were systematically reviewed to evaluate the efficacy and safety profiles of patients with renal stones who were treated with PCNL or RIRS. Main outcomes measures included stone-free rate, operative time, hospital stay, and complication rate. Results were expressed as risk ratio (RR), or weighted mean difference (WMD) with 95% confidence intervals (CIs). Pooled estimates were calculated using a fixed-effects or random-effects model according to the heterogeneity among the studies. In total, 17 studies [4 randomized controlled trials (RCTs) and 13 cohort studies] involving 1,717 patients met the inclusion criteria, and were included in this meta-analysis. Pooled results showed that PCNL exhibited a significantly higher stone-free rate (RR=0.90, 95% CI: 0.86 to 0.95; P<0.001) but was associated with a longer hospital stay, when compared with RIRS (WMD=-2.72, 95% CI: -3.9 to -1.54; P<0.001). Operative time (WMD=7.86, 95% CI: -0.89 to 16.61; P=0.078) and complication rate (RR=0.71, 95% CI: 0.48 to 1.05; P=0.083) did not significantly differ between the groups. Subgroup analysis revealed that PCNL had a shorter operation time than RIRS in patients with stone sizes ≥2 cm (WMD=12.88, 95% CI: 4.77 to 20.99; P=0.002), and PCNL had a similar stone-free rate as RIRS when the estimates were pooled from RCTs (RR=0.88, 95% CI: 0.76 to 1.01; P=0.078). Compared with PCNL, RIRS had a significantly lower stone-free rate, shorter hospital stay, but a similar operation time and complication rate. Therefore, we propose that RIRS may be an alternative therapy to PCNL, with acceptable efficacy and complication rates for renal stones. Further large-scale, well-conducted RCTs are required to verify our findings.

Sheathless and fluoroscopy-free retrograde intrarenal surgery: An attractive way of renal stone management in high-volume stone centers

Objective

To evaluate the efficacy and safety of sheathless and fluoroscopy-free flexible ureterorenoscopic laser lithotripsy (FURSL) for treating renal stones.

Methods

Between May 2015 and May 2017, 135 patients with renal stones treated with sheathless and fluoroscopy-free FURSL were prospectively evaluated. Our technique involved a semi-rigid ureteroscopic assessment of the ureter, and the guidewire was left in situ to railroad the flexible ureteroscope. A holmium laser was used to fragment and dust the stones; fragments were neither grasped nor collected.

Results

The study population consisted of 135 patients including 85 males (62.96%) and 50 females (37.04%) with a mean age of 40.65 years (range: 3–70 years) were evaluated. The mean stone size was 17.23 mm (range: 8–41 mm). Complete stone-free status was achieved in 122 (90.37%) patients and clinically insignificant residual fragments (CIRF) in two (1.48%), while residual stones were still present in 11 (8.15%) patients. Postoperative complications occurred in 23 (17.4%) cases and were mostly minor, including fever in 17 (12.6%), pyelonephritis in four (3.0%), subcapsular hematoma in one (0.7%) and steinstrasse in one (0.7%). These complications were Clavien I-II, GI in 17 (12.6%) patients, GII in five (3.7%), and Clavien IIIb in one (0.7%). No major complications were observed. Stone size ≥2 cm, operative time ≥30 min, and lasing time ≥20 min were significantly associated with a higher rate of complications and lower stone-free rates upon univariate analysis (p<0.05).

Conclusion

Sheathless and fluoroscopy-free FURSL are effective and safe for renal stone management, especially for stones under 2 cm in diameter. This process is a feasible option for avoiding sheath complications, which can protect surgeons from the negative effects of radiation.

Contemporary best practice in the management of staghorn calculi

Staghorn calculi are complex renal stones that occupy the majority of the renal collecting system. These stones are associated with high morbidity and can lead to recurrent urinary tract infections, urosepsis, renal deterioration, and death if left untreated. Managing patients with staghorn calculi can be challenging. Fortunately, advances in technology and endourology techniques have enabled urologists to effectively treat these stones with minimal morbidity to the patient. This article describes the contemporary best practices in the initial evaluation, management, and follow up of patients with staghorn calculi to help the practicing urologist navigate this complex condition.

Safety and efficacy of retrograde intrarenal surgery for the treatment of renal stone in solitary kidney patients

Purpose: We present our experience of retrograde intrarenal surgery (RIRS) for the treatment of renal stones in patients with solitary kidneys and evaluate the safety and efficacy of this treatment modality.

Materials and methods: Between March 2011 and July 2015, the clinical records of 60 patients with renal stones in solitary kidneys who underwent RIRS were retrospectively reviewed. Demographic characteristics, preoperative urinary culture, blood biochemistry, stone location, and surface area were documented. The final stone-free rates (SFRs) were assessed one month after the last treatment session by computed tomography (CT). Preoperative, operative, and postoperative parameters were analyzed. Serum creatinine (Scr) and glomerular filtration rate (GFR) were measured preoperatively, one month postoperatively, and at each follow-up visit.

Results: The mean stone burden was 628 ± 27.2 mm² (range 301–1199). The mean operative time was 84.4 ± 21.3 min (range 40–115). The mean drop in postoperative hemoglobin was 0.6 ± 0.21 g/dL (range 0.1–0.7). Twelve patients (20%) required second-stage RIRS for residual stones. The SFRs after the single and second procedures were 80% and 95%, respectively. The mean preoperative Scr level was 111.6 ± 45.59 μmol/L, and the mean postoperative Scr level was 96.7 ± 34.12 μmol/L. The change was statistically significant (p = .008). The same findings were observed for GFR. The mean preoperative GFR was 65.04 ± 25.37 ml/min, and the mean postoperative GFR was 76.89 ± 27.2 ml/min (p = .023). Minor complications occurred in nine patients (15%). One patient experienced septic shock and acute renal failure due to steinstrasse. This patient required hemodialysis and percutaneous nephrostomy drainage. One patient developed perirenal abscess and was treated with percutaneous drainage.

Conclusion: RIRS is a safe and effective procedure for the treatment of renal stones in patients with solitary kidneys. RIRS did not adversely affect renal function at either the short-term or the long-term follow-up.

Retrograde intrarenal surgery: An expanding role in treatment of urolithiasis

During the past 3 decades, the surgical management of kidney stones has undergone many technological advances and one is the development of the flexible ureteroscopy. The development of this instrument as well as ancillary equipment such as baskets, graspers, and others, and improvements in lithotripsy with Holmium: YAG laser have led to expand its indications with diagnostic and therapeutic management of medical issues of the upper urinary tract such as urolithiasis and urothelial tumors. The objective of this review is to describe its indications and results in the different scenarios for the treatment of urinary stones.

Comparative study of the treatment of 20-30 mm renal stones with miniaturized percutaneous nephrolithotomy and flexible ureterorenoscopy in obese patients

PURPOSE

To evaluate and compare flexible ureteroscopy (f-URS) and mini-percutaneous nephrolithotomy (mPNL) for 20-30 mm renal stones in obese patients regarding efficacy and safety.

METHODS

Between May 2011 and June 2017, 254 obese patients who had 20-30 mm kidney stone were consecutively included in the study; 106 patients underwent mPNL and 148 underwent f-URS by the same surgeon. The following parameters were retrospectively assessed: patient and stone characteristics, surgical details, perioperative outcomes, and stone-free rates (SFR).

RESULTS

F-URS group was similar to mPNL group in terms of the mean duration of surgery (92.8 ± 26.1 vs 87.4 ± 31.5 min, P = 0.137) and the final SFR (89.1 vs 92.5%, P = 0.381). The f-URS group had significantly shorter postoperative stay (1.0 ± 0.8 vs 4.3 ± 1.7 days, P < 0.001) and lower postoperative complications (11.5 vs 26.4%, P = 0.002). However, the f-URS group had a lower SFR after first session (67.2 vs 87.4%, P < 0.001) and needed more number of procedures (1.5 ± 0.4 vs 1.3 ± 0.4, P < 0.001) than the mPNL group.

CONCLUSIONS

MPNL has a higher efficacy (higher SFR after first session and lower number of procedures); however, f-URS offers advantages regarding safety (lower complication rate). Therefore, both options can be offered to obese patients with renal stones from 20 to 30 mm in size. Nevertheless, these results must be confirmed by further prospective randomized trials.

Comparative analysis between percutaneous nephrolithotomy and flexible ureteroscopy in kidney stones of 2-3cm

INTRODUCTION

To compare percutaneous nephrolithotomy and flexible ureterorenoscopy for treating kidney stones between 2 and 3cm.

MATERIAL AND METHODS

A prospective, comparative, nonrandomised study was conducted with 108 patients with kidney stones between 2 and 3cm. Fifty-four patients underwent percutaneous nephrolithotomy and 54 underwent flexible ureteroscopy. We compared the following variables: lithiasis-free rate (%), surgical time, the need for an auxiliary process, postoperative complications, hospital stay, readmission rates and recovery time.

RESULTS

There were no differences in the lithiasis-free rate between the 2 surgical techniques (76% for ureteroscopy vs. 87% for nephrolithotomy; P=.1) or in the complications (29% for nephrolithotomy vs. 27% for ureteroscopy; P=.4). A larger number of auxiliary process were needed for the ureteroscopy group (20%) than for the nephrolithotomy group (7%) (P=.04). The surgical time was longer for the nephrolithotomy group (121±52min) than for the ureteroscopy group (93±42min) (P=.004). The ureteroscopy group had shorter hospital stays (2.1±1.6 vs. 3.9±1.9 days; P=.002), shorter convalescence (8.1±4.9 vs. 13.3±4.2 days; P=.005) and higher readmission rates (7.4% vs. 0%, P=.05) than the nephrolithotomy group.

CONCLUSIONS

Nephrolithotomy and ureteroscopy have similar efficacy for treating kidney stones measuring 2-3cm, with no differences in complications. Ureteroscopy results in shorter hospital stays, quicker recoveries but more readmissions and a greater need for auxiliary procedures.

Comparison of absorbed irrigation fluid volumes during retrograde intrarenal surgery and percutaneous nephrolithotomy for the treatment of kidney stones larger than 2 cm

Purpose

Irrigation-induced increase in intrarenal pressure is of concern because it may cause infection due to increased pyelovenous and pyelolymphatic absorption. This study is the first to compare prospectively the absorbed fluid volumes during percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for stones larger than 2 cm.

Materials and methods

General anesthesia was applied to all patients. Isotonic solution containing 1 % ethanol was used as irrigation fluid. Venous blood ethanol concentration was first measured with the start of irrigation and thereafter every 15 min until the patients left the recovery room. Absorbed fluid volumes were measured using the blood ethanol concentrations. Duration of irrigation, irrigated fluid volume, stone size and grade of hydronephrosis were also recorded.

Results

A total of 60 patients were included the study. Fluid absorption occurred in all patients. Minimum and maximum ranges of fluid absorption were 20–573 mL for RIRS and 13–364 mL for PCNL. The increase in fluid absorbed volume was observed as a result of the given amount of irrigating fluid used in the PCNL group. Also prolongation of operation led to a significant increase in absorption in the PCNL group. Increase in body mass index, stone size, and hydronephrosis did not affect fluid absorption significantly in either of the two operation techniques in correlation analyzes.

Conclusion

Both RIRS and PCNL are conducted under high pressure and can be accompanied potential complications such as SIRS. The fluid absorption confirmed in our study should be taken into consideration during RIRS and PCNL.

Outcome analysis of holmium laser and pneumatic lithotripsy in the endoscopic management of lower ureteric calculus in pediatric patients: a prospective study

Objective:

To analyse outcomes of holmium laser and pneumatic lithotripsy in treatment of lower ureteric calculus in pediatric patients.

Materials and methods:

Prospective study conducted between August 2013 and July 2015. Inclusion criteria were lower ureteric calculus with stone size ≤1.5cms. Exclusion criteria were other than lower ureteric calculus, stone size ≥1.5cms, congenital renal anomalies, previous ureteral stone surgery. Patients were divided into two groups. Group A underwent pneumatic and group B underwent laser lithotripsy procedure. Patient's baseline demographic and peri-operative data were recorded and analysed. Post operatively X-ray/ultrasound KUB (Kidney, ureter and bladder) was performed to assess stone free status.

Results:

A total of 76 patients who met the inclusion criteria to ureteroscopic intracorporeal lithotripsy were included. Group A and B included 38 patients in each. Mean age was 12.5±2.49 in Group A and 11.97±2.74 years in Group B respectively (p=0.38). Overall success rate was 94.73% in Group A and 100% in Group B, respectively (p=0.87).

Conclusion:

Holmium Laser lithotripsy is as efficacious as pneumatic lithotripsy and can be used safely for the endoscopic management of lower ureteric calculus in pediatric patients. However, holmium laser requires more expertise and it is a costly alternative.

Fluoroscopy free flexible ureteroscopy with holmium: Yttrium-aluminium-garnet laser lithotripsy for removal of renal calculi

Objective

To evaluate the feasibility of access sheath insertion and ureteric stent placement without image guidance in flexible ureteroscopic lithotripsy with holmium:yttrium-aluminium-garnet laser for renal stones.

Patients and methods

Between March 2014 and October 2015, 80 patients with renal stones treated with flexible ureteroscopic laser lithotripsy were evaluated. Indications for surgery were renal obstruction, failed shockwave lithotripsy (SWL), stones in polycystic kidneys, and mal-rotated kidneys. A 6.5-F Cobra flexible ureteroscope was used in all cases with an access sheath of 12 F, 35/45 cm in length. Fluoroscopy was not intended for use in all cases and postoperative JJ stenting was optional. The perioperative complications were listed and the collected data were analysed.

Results

The study included 80 patients (66 male, 14 female), with a mean (SD; range) age of 48.2 (8; 28–54) years and a stone burden of 13 (3.5; range 6–23) mm. In all, 26 patients had a stone burden of >15 mm and 48 patients had lower calyceal stones. The mean (SD; range) operative time was 71.5 (20; 25–130) min. Overall, 76 (95%) access sheath insertions were performed successfully without the use of fluoroscopy. JJ stenting was used in 22 patients (27.5%). The mean (SD; range) hospital stay was 10 (8.5; 10–36) h. After one session, a stone-free rate (SFR) of 87.5% was achieved (93.3% for stones of <15 mm). A single session was successful in 87.9% of cases with lower calyceal stones, with a SFR of 91.7% for post-SWL failure cases. The perioperative complication rate was 15%.

Conclusion

Access sheath insertion without fluoroscopic guidance is feasible. This technique reduces radiation exposure in patients requiring flexible ureteroscopy.

Intrarenal Surgery vs Percutaneous Nephrolithotomy in the Management of Lower Pole Stones Greater than 2 cm

Purpose

To compare the efficacy of RIRS and PNL in lower pole stones ≥2 cm. Materials and and Methods: A total of 109 patients who underwent PNL or RIRS for solitary lower pole stone between April 2009 and December 2012, were retrospectively analyzed. Lower pole stone was diagnosed with CT scan. Stone size was assessed as the longest axis of the stone. All patients were informed about the advantages, disadvantages and probable complications of both PNL and RIRS before the selection of the procedure. Patients decided the surgery type by themselves without being under any influences and written informed consent was obtained from all patients prior to the surgery. Patients were divided into two groups according to the patients’ preference of surgery type. Group 1 consisted of 77 patients who underwent PNL and Group 2 consisted of 32 patients treated with RIRS. Stone free statuses, postoperative complications, operative time and hospitalization time were compared in both groups.

Results

There was no statistical significance between the two groups in mean age, stone size, stone laterality, mean follow-up periods and mean operative times. In PNL group, stone-free rate was 96.1% at first session and 100% after the additional procedure. In Group 2, stone-free rate was 90.6% at the first procedure and 100% after the additional procedure. The final stone-free rates and operative times were similar in both groups.

Conclusions

RIRS should be an effective treatment alternative to PNL in lower pole stones larger than 2 cm, especially in selected patients.

Miniperc and retrograde intrarenal surgery: when and how?

CONTEXT

Extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) are consolidated procedures for the treatment of kidney stones; however, their primary weak points are the lower efficacy of ESWL, especially for lower calyx stones, and the morbidity of PCNL resulting from the creation and dilation of the percutaneous trajectory. The increasing miniaturization of percutaneous surgery instrumentation and the development of retrograde intrarenal surgery (RIRS) are recent innovations.

ACQUISITION OF EVIDENCE

A structured nonsystematic review was conducted through a literature search of articles published between 1997 and 2013, using the terms kidney stones, miniperc, mini-PCNL, RIRS and flexible ureteroscopy in the PubMed, Google Scholar and Scopus databases.

SUMMARY OF THE EVIDENCE

RIRS requires greater surgical time, several procedures for voluminous stones and higher hospital costs, due in part to the relative fragility of the instruments. On the other hand, miniperc requires a longer hospital stay, an increased need for postoperative analgesia and a greater reduction in hemoglobin levels, although these do not translate into an increased rate of transfusions.

CONCLUSIONS

The current treatment of kidney stones uses minimally invasive procedures such as miniperc and RIRS. The 2 procedures are equivalent in terms of efficacy (stone clearance) and are associated with minimal complications. Comparative prospective studies are necessary to determine the position of each of these techniques in the treatment of kidney stones. In our experience, the 2 techniques are complementary and should be part of the current urological therapeutic arsenal.

Evidence for Ureterorenoscopy and Laser Fragmentation (URSL) for Large Renal Stones in the Modern Era

Large renal stones (>2 cm) are managed with percutaneous nephrolithotomy (PCNL), which has a good stone-free rate (SFR) but a relatively high incidence of complications graded Clavien ≥ 3. We wanted to review the literature for the use of ureterorenoscopy and laser fragmentation (URSL) for the management of these stones. A systematic review was done from 1990 to April 2014 for all English language articles reporting on a minimum of 10 patients for stones >2 cm in size (done by 2 reviewers independently) in accordance with the PRISMA and Cochrane review guidelines. A total of 379 articles were identified and after screening for the titles (54) and abstracts (29), 12 papers (651 patients) were included. The male to female ratio was 356:232 with a mean age of 54 years (range 16-86 years). With a mean stone size of 2.7 cm (2-3.15 cm) and the mean operating time of 96 min (28-238 min); the SFR was 91 % (1.45 procedures/patient). The overall number of complications was 58 (8.6 %) of which 26 (4.5 %) were complications classed Clavien ≥ 3 (haematuria with subcapsular haematoma/clot retention-7; ureteral perforation-7; steinstrasse-5; sepsis/pyelonephritis-5; prostatitis-1; cerebrovascular accident-1). Ureterorenoscopy for large renal stones in the modern era has good SFR with a small risk of major complications.

Flexible ureteroscopy: Technological advancements, current indications and outcomes in the treatment of urolithiasis

The last 3 decades have witnessed great improvements in the technology and clinical applications of many minimally invasive procedures in the urological field. Flexible ureteroscopy (fURS) has advanced considerably to become a widely utilized diagnostic and therapeutic tool for multiple upper urinary tract pathologies. The most common indication for fURS is the treatment of upper urinary tract stones with the aid of Holmium:Yttrium Aluminium Garnet (YAG) laser lithotripsy. Advancements in endoscope technologies and operative techniques have lead to a broader application of fURS in the management of urolithiasis to include larger and more complex stones. fURS has proved to be an effective and safe procedure with few contraindications. Continued progression in fURS may increase its clinical applicability and supplant other procedures as the first line treatment option for urolithiasis.

Influence of Pelvicaliceal Anatomy on Stone Clearance After Flexible Ureteroscopy and Holmium Laser Lithotripsy for Large Renal Stones

PURPOSE

This study was performed to evaluate the impact of pelvicaliceal anatomy on stone clearance in patients with remnant fragments in the lower pole after flexible ureteroscopy and holmium laser lithotripsy (fURSL) for renal stones >15 mm.

PATIENTS AND METHODS

This retrospective study included 67 patients with radiopaque residual fragments (>2 mm) in the lower pole after fURSL for large renal stones (>15 mm). The preoperative infundibular length (IL), infundibular width (IW), infundibulopelvic angle (IPA), and caliceal pelvic height (CPH) were measured using intravenous urography. Multivariate analysis was performed to determine whether any of these measurements affected stone clearance.

RESULTS

Of the 67 patients, 55 (82.1%) were stone free (SF) 3 months after fURSL. The anatomic factors significantly favorable for an SF status were a short IL, broad IW, wide IPA, and low CPH. On multivariate analysis, the IPA had a significant influence on an SF status after fURSL (p=0.010). An IPA <30° was a negative risk factor (p=0.019). Postoperative complications occurred in nine patients (13.4%), including Clavien grade I complications in two patients (2.9%), grade II in six patients (8.9%), and grade IIIa in one patient (1.8%). Almost all complications were minor.

CONCLUSIONS

An IPA <30° is the only negative risk factor for stone clearance after fURSL for large renal stones according to our multivariate analysis. Additional studies are required to further evaluate the characteristics of the pelvicaliceal anatomy influencing stone clearance.

Ureteroscopy and laser lithotripsy: technologic advancements

Ureteroscopic lithotripsy has evolved since the first reported cases employing rigid rod-lens endoscopes and stiff ultrasonic lithotrites. Fiber optics facilitated rigid endoscope miniaturization and the development of a steerable, deflectable flexible ureteroscopes. Over 30 years of technical innovations culminating in digital imagers and powerful, precise laser lithotrites, complimented by progressive endoscopic techniques have produced efficient endoscopic therapies with minimal morbidity and commonly performed in an outpatient setting.

Retrograde intrarenal surgery versus percutaneous nephrolithotomy for treatment of renal stones >2 cm: a meta-analysis

OBJECTIVE

To systematically review the efficacy and safety of retrograde intrarenal surgery (RIRS) versus percutaneous nephrolithotomy (PCNL) for the treatment of renal calculi >2 cm.

METHODS

We searched PubMed, Cochrane Library, Embase and the Chinese Biomedical Literature Database about RIRS and PCNL for the treatment of renal stones. The retrieval time ended in December 2013. All clinical trials were retrieved and their included references investigated. Two reviewers independently assessed the quality of all included studies, and the eligible studies were included and analyzed using the RevMan 5.2 software.

RESULTS

Two randomized controlled trials and six clinical controlled trials were included, involving a total of 590 patients. Our meta-analysis showed that there were not significant differences in stone-free rate (relative risk [RR] = 0.95, 95% confidence interval (CI) 0.88-1.02, p = 0.11) and fever (RR = 0.95, 95% CI 0.54-1.67, p = 0.85) between RIRS and PCNL. We found that hospital stay (weighted mean difference [WMD] = -2.10, 95% CI -3.08 to -1.11, p < 0.10) and bleeding (RR = 0.20, 95% CI 0.06-0.68, p = 0.01) were lower and operation time was longer (WMD = 19.11, 95% CI 7.83-30.39, p < 0.10) for RIRS.

CONCLUSION

RIRS is a safe and effective procedure. It can successfully treat patients with stones >2 cm with a high stone-free rate and significantly reduce hospital stay without increasing complications. RIRS can be used as an alternative treatment to PCNL in selected cases with larger renal stones. However, further randomized trials are needed to confirm these findings.

Efficacy and safety of Ho:YAG laser lithotripsy for ureteroscopic removal of proximal and distal ureteral calculi

Background

Laser lithotripsy is an established endourological modality. Ho:YAG laser have broadened the indications for ureteroscopic stone managements to include larger stone sizes throughout the whole upper urinary tract. Aim of current work is to assess efficacy and safety of Ho:YAG laser lithotripsy during retrograde ureteroscopic management of ureteral calculi in different locations.

Methods

88 patients were treated with ureteroscopic Ho:YAG laser lithotripsy in our institute. Study endpoint was the number of treatments until the patient was stone-free. Patients were classified according to the location of their stones as Group I (distal ureteric stones, 51 patients) and group II (proximal ureteral stones, 37). Group I patients have larger stones as Group II (10.70 mm vs. 8.24 mm, respectively, P = 0.020).

Results

Overall stone free rate for both groups was 95.8%. The mean number of procedures for proximal calculi was 1.1 ± 0.1 (1–3) and for distal calculi was 1.0 ± 0.0. The initial treatment was more successful in patients with distal ureteral calculi (100% vs. 82.40%, respectively, P = 0.008). No significant difference in the stone free rate was noticed after the second laser procedure for stones smaller versus larger than 10 mm (100% versus 94.1%, P = 0.13). Overall complication rate was 7.9% (Clavien II und IIIb). Overall and grade-adjusted complication rates were not dependant on the stone location. No laser induced complications were noticed.

Conclusions

The use of the Ho:YAG laser appears to be an adequate tool to disintegrate ureteral calculi independent of primary location. Combination of the semirigid and flexible ureteroscopes as well as the appropriate endourologic tools could likely improve the stone clearance rates for proximal calculi regardless of stone-size.

Comparison of Ho:YAG laser and pneumatic lithotripsy in the treatment of impacted ureteral stones: an analysis of risk factors

The aim was to compare pneumatic and holmium:yttrium-aluminum-garnet laser in the treatment of impacted ureteral stones with different locations and to identify the risk factors for complications. Between March 2005 and November 2012, a total of 230 patients underwent ureteroscopic lithotripsy for impacted stones. Of the patients, 117 had pneumatic and 113 had laser lithotripsy for the fragmentation of the stones. Treatment outcomes based on evidence of being stone free were evaluated. Preoperative, operative, and postoperative follow-up findings were analyzed and compared. There was a difference between the two groups according to overall stone clearance rate (93.8% vs. 80.3%, p = 0.002). There was no statistically significant difference for distal location between the laser and pneumatic groups (96.8% vs. 91.7%, p =0.288). For 10 patients with intrarenally migrated stones who were managed with flexible ureterorenoscopy in the same session, laser lithotripsy was more successful than pneumatic for proximal ureteral stone (94.4% vs. 67.9%, p = 0.007). The overall complication rate was 26.1%. There was no statistically significant difference between the two groups (29% vs. 23%, p = 0.296). Multivariate logistic regression analysis revealed that the proximal location was a statistically significant parameter for the occurrence of complications in both groups (p = 0.001 for PL, p = 0.004 for laser). The pneumatic and holmium:yttrium-aluminum-garnet laser lithotripsy are effective in the treatment of distal impacted stones. Both treatments with semirigid ureteroscopy are acceptable for proximal impacted ureteral stones, but holmium laser lithotripsy has an advantage of use with flexible ureteroscope for intrarenally migrated stone.

Combined semirigid and flexible ureterorenoscopy via a large ureteral access sheath for kidney stones >2 cm: a bicentric prospective assessment

PURPOSE

The international guidelines on urolithiasis state that the percutaneous approach is superior for kidney stones ≥20 mm. Nevertheless, several groups have reported high stone-free rates (SFRs) with low morbidity for ureteroscopic treatment of calculi >15 mm. We hereby describe a new technique including the combined use of semirigid and flexible ureteroscopy via a large ureteral access sheath (UAS).

METHODS

The proposed technique includes (a) preoperative ureteral stenting, (b) use of a large lumen UAS (14/16F, 35 cm), (c) use of a semirigid ureteroscope, (d) holmium laser lithotripsy, (e) passive and (f) active fragment extraction, and finally, the removal of caliceal stones (g) using a flexible scope. We conducted a prospective outcome analysis for 38 patients treated at two tertiary university centers.

RESULTS

Perioperative data were as follows: median cumulative stone size 24.5 mm (20-60), median operating time 95 min (50-205), post-operative ureteral stenting (2-35 days) in 33 patients (86.8 %), Clavien complications 2 and 3 in 7.9 %, primary SFR 63.2 %, and overall computed tomography (CT) controlled SFR after 3 months 81.8 % (including staged procedures). No late complications were observed.

CONCLUSIONS

The combined use of semirigid ureteroscopy and an UAS further develops the endoscopic treatment of kidney stones. This is the first series of this kind that confirms high SFRs by CT. The approach has significant advantages: Superior irrigation and outflow enhance both vision and stone clearance, and multiple ureteral passages without putting the ureter at injury risk. These encouraging results make this modality an appealing alternative to percutaneous nephrolithotomy.

Clinical effectiveness of the PolyScope™ endoscope system combined with holmium laser lithotripsy in the treatment of upper urinary calculi with a diameter of less than 2 cm

The aim of this study was to evaluate the clinical value of the PolyScope™ endoscope system in the treatment of upper urinary calculi with a diameter of <2 cm. A total of 86 patients hospitalized with upper urinary tract calculi were included. The patients were placed under general or spinal anesthesia and in a lithotomy position. Following the dilation of the ureter, a guide wire was inserted under the direct vision of an F8/9.8 rigid ureteroscope, and an F12/14 flexible ureteral access sheath was positioned along the guide wire. Holmium laser lithotripsy was subsequently performed, using an F8.0 ‘PolyScope’ modular flexible ureteroscope. Plain film of the kidney-ureter-bladder (KUB) was performed 1 day subsequent to the surgery, in order to determine the result of the lithotripsy and the position of the double-J stent which was inserted after after holmium laser lithotripsy. In addition, in certain patients, KUB radiography was performed 2–4 weeks subsequent to the surgery, and extracorporeal shockwave lithotripsy (ESWL) was performed if the diameter of the residual stones was >6 mm. Lithotripsy was successful in 77 patients and the duration of the surgery ranged between 25 and 80 min (mean duration, 42 min). Little bleeding was observed. Three patients presented with a slight fever following the surgery; however, no ureteral perforation, high fever or septicemia was observed among the patients following anti-inflammatory treatment. The stone-free rate (SFR) of the single-pass lithotripsy was 89.5% (77/86) and the SFR with ESWL was 96.5% (83/86). The study demonstrated that the F8 modular flexible ureteroscope was safe, convenient and effective for the lithotripsy of upper-tract calculi.

Flexible ureteroscopy and laser lithotripsy for stones >2 cm: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Urinary stones >2 cm are traditionally managed with percutaneous nephrolithotomy (PCNL). Recently, flexible ureteroscopy and laser lithotripsy) (FURSL) has been used to manage them with comparable results. In a comparative study of renal stones between 2 and 3 cm, FURSL was reported to need less second-stage procedures and be just as effective as PCNL. Our purpose was to review the literature for renal stones >2 cm managed by ureteroscopy and holmium lasertripsy.

MATERIALS AND METHODS

A systematic review and quantitative meta-analysis was performed using studies identified by a literature search from 1990s (the first reported large renal stones treated ureteroscopically) to August 2011. All English language articles reporting on a minimum of 10 patients treated with FURSL for renal stones >2 cm were included. Two reviewers independently extracted the data from each study. The data of studies with comparable results were included into a meta-analysis.

RESULTS

In nine studies, 445 patients (460 renal units) were reportedly treated with FURSL. The mean operative time was 82.5 minutes (28-215 min). The mean stone-free rate was 93.7% (77%-96.7%), with an average of 1.6 procedures per patient. The mean stone size was 2.5 cm. An overall complication rate was 10.1%. Major complications developed in 21 (5.3%) patients and minor complications developed in 19 (4.8%) patients. A subgroup analysis shows that FURSL has a 95.7% stone-free rate with stones 2-3 cm and 84.6% in those >3 cm (P=0.01), with a minor complication rate of 14.3% and 15.4%, respectively, and a major complication rate of 0% and 11.5%, respectively.

CONCLUSION

In experienced hands, FURSL can successfully treat patients with stones >2 cm with a high stone-free rate and a low complication rate. Although the studies are from high-volume experienced centers and may not be sufficient to alter everyday routine practice, this review has shown that the efficacy of FURSL allows an alternative to PCNL.

Ureteroscopic treatment of larger renal calculi (>2 cm)

Objectives

To evaluate the current status of ureteroscopic lithotripsy (UL) for treating renal calculi of >2 cm, as advances in flexible ureteroscope design, accessory instrumentation and lithotrites have revolutionised the treatment of urinary calculi. While previously reserved for ureteric and small renal calculi, UL has gained an increasing role in the selective management of larger renal stone burdens.

Methods

We searched the available databases, including PubMed, Google Scholar, and Scopus, for relevant reports in English, and the article bibliographies to identify additional relevant articles. Keywords included ureteroscopy, lithotripsy, renal calculi, and calculi >2 cm. Retrieved articles were reviewed to consider the number of patients, mean stone size, success rates, indications and complications.

Results

In all, nine studies (417 patients) were eligible for inclusion. After one, two or three procedures the mean (range) success rates were 68.2 (23–84)%, 87.1 (79–91)% and 94.4 (90.1–96.7)%, respectively. Overall, the success rate was >90% with a mean of 1.2–2.3 procedures per patient. The overall complication rate was 10.3%, including six (1.4%) intraoperative and 37 (8.9%) postoperative complications, most of which were minor. The most common indications for UL were a failed previous treatment (46%), comorbidities (18.2%), and technical and anatomical factors (12.3%).

Conclusions

UL is safe and effective for treating large renal calculi. While several procedures might be required for total stone clearance, UL should be considered a standard approach in the urologist’s options treating renal calculi of >2 cm.