Ureteroscopic treatment of renal calculi

Massive retroperitoneal hematoma as an acute complication of retrograde intrarenal surgery: A case report

BACKGROUND

Retrograde intrarenal surgery (RIRS) has been proven to be a safe and effective treatment modality in large-scale quantitative studies. However, although its safety profile has been established, it also has a potential risk of life-threatening complications. We here describe our experience with a patient who developed a huge periureteral hematoma after RIRS with holmium laser lithotripsy.

CASE SUMMARY

A 73-year-old woman visited our center with a complaint of gross hematuria. An enhanced computed tomography (CT) scan revealed a 1.5-cm left renal pelvis stone with hydronephrosis. The patient underwent RIRS. During the surgery, a 12/14-Fr ureteral access sheath was applied and a 6-Fr ureteral catheter was indwelled thereafter. On postoperative day 1, she experienced aggravated left flank pain and left lower-quadrant tenderness without rebound tenderness. A follow-up CT scan was taken, which revealed a huge hematoma in the periureteral space, not in the perirenal space, with suspicious contrast medium extravasation. Immediate angiography was performed; however, it showed no evidence of active bleeding. She was conservatively managed with hydration and antibiotic and nonsteroidal anti-inflammatory drug therapy, and was discharged on postoperative day 7. However, she visited our outpatient department with recurrent left flank pain at 5 d from discharge. Ultrasonography confirmed that the double J-stent was intact. To rule out stent malfunction, the stent was changed. Decreased size of the hematoma was observed in the imaging studies, and conservative management for candiduria was performed for 1 wk.

CONCLUSION

Although RIRS is an effective and safe procedure for the management of renal stones, clinicians should be aware of its potential complications.

Prospective Randomized Trial Comparing the Safety and Clarity of Water Versus Saline Irrigant in Ureteroscopy

BACKGROUND

Water irrigant is discouraged in ureteroscopy due to risks demonstrated in more invasive endoscopic procedures. However, water is not well studied in ureteroscopy and may provide better visualization than standard saline.

OBJECTIVE

To determine whether water irrigant increases the risk of hyponatremia compared with saline and provides better visualization in ureteroscopy.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, prospective, double-blinded trial was conducted. In 2017, eligible adult ureteroscopy patients at a university hospital were recruited for the study.

INTERVENTION

Participants randomized to water or saline irrigant in ureteroscopy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Serum sodium and osmolality, body temperature, subjective surgeon visualization, and objective turbidity clarity were analyzed. Chi-square or Fisher's exact tests for categorical variables and analysis of variance test for continuous variables were performed.

RESULTS AND LIMITATIONS

A total of 121 individuals (mean age 57 ± 15 yr) underwent ureteroscopy (mean time 35 ± 18 min) with a mean irrigation volume of 839 ± 608 ml. For the 101 (83%) patients who had nephrolithiasis, the mean number of stones was 2 ± 1 and the mean stone burden was 13 ± 7 mm. There were no significant differences in demographic, clinical, and intraoperative variables between water and saline groups, except for a higher body mass index in the saline group (p = 0.01). There was no significant difference between groups in the incidence of hyponatremia, hypo-osmolality, or hypothermia. The median surgeon visualization score was significantly higher using water (p < 0.01). The mean turbidity was significantly lower with water (p = 0.02). Limitations were not objectively assessing hemolysis or fluid absorption.

CONCLUSIONS

Water irrigant does not increase the incidence of hyponatremia in uncomplicated ureteroscopy and provides clearer visualization than saline.

PATIENT SUMMARY

We compared safety and clarity of water and saline irrigation, which aid surgeon visualization, in ureteroscopy, which can treat kidney stones. We found that water irrigant does not reduce blood sodium levels significantly compared with saline in ureteroscopy and provides better visualization.

Is semirigid ureteroscopy sufficient in the treatment of proximal ureteral stones? When is combined therapy with flexible ureteroscopy needed?

The goals of this study were to examine cases of proximal ureteral stones in which semirigid or flexible ureteroscopes alone were insufficient for endoscopic treatment, requiring the combination of both. A total of 137 patients were retrospectively evaluated. Holmium laser was used as the energy source for stone fragmentation. Each operation was begun with a 6/7.5 Fr semirigid ureteroscope (URS), and continued with a 7.5 Fr flexible URS in those procedures that failed to reach the stone or push-up. Double J stents were inserted into those patients in whom the flexible URS failed. Shock wave lithotripsy (SWL) or a repeat ureteroscopy (after 2-4 weeks) was planned in those patients who were considered to be treated unsuccessfully. The demographic features of the patients, stone sizes, treatment outcomes, need for additional treatment, complications, and the results of the postoperative 1-month early follow-up were evaluated. The mean age of the patients (77 males and 60 females) was 38 ± 6.7 years old, the mean stone size was 12.3 ± 3.7 mm, and the number of patients with persistent hydronephrosis was 86 (62.8 %). A stone-free diagnosis was achieved in a total of 124 patients (90.5 %), using a semirigid URS in 80 patients and a flexible URS in 44 patients. Treatment using a flexible URS was administered in 38 patients (27.7 %) due to push-up, and in 6 patients (4.3 %) because of the failure to advance the semirigid URS into the ureter. The treatment failed in 13 patients (9.4 %) despite the use of both methods. Treatment using low-caliber semirigid ureteroscopy and a holmium laser is possible, regardless of the stone size, in female patients without hydronephrosis. However, the need for combined treatment with flexible ureteroscopy is increased in male patients with hydronephrosis.

Predictive factors for flexible ureterorenoscopy requirement after rigid ureterorenoscopy in cases with renal pelvic stones sized 1 to 2 cm

Purpose

To evaluate the outcomes of rigid ureterorenoscopy (URS) for renal pelvic stones (RPS) sized 1 to 2 cm and to determine the predictive factors for the requirement for flexible URS (F-URS) when rigid URS fails.

Materials and Methods

A total of 88 patients were included into the study. In 48 patients, the RPS were totally fragmented with rigid URS and F-URS was not required (group 1). In 40 patients, rigid URS was not able to access the renal pelvis or fragmentation of the stones was not completed owing to stone position or displacement and F-URS was utilized for retrograde intrarenal surgery (RIRS) (group 2). The predictive factors for F-URS requirement during RIRS for RPS were evaluated. Both groups were compared regarding age, height, sex, body mass index, stone size, stone opacity, hydronephrosis, and previous treatments.

Results

The mean patient age was 48.6±16.5 years and the mean follow-period was 39±11.5 weeks. The overall stone-free rate in the study population was 85% (75 patients). In groups 1 and 2, the overall stone-free rates were 83% (40 patients) and 87% (35 patients), respectively (p>0.05). The independent predictors of requirement for F-URS during RIRS were male gender, patient height, and higher degree of hydronephrosis.

Conclusions

Rigid URS can be utilized in selected patients for the fragmentation of RPS sized 1 to 2 cm with outcomes similar to that of F-URS. In case of failure of rigid URS, F-URS can be performed successfully in this group of patients.

Internet-Based Patient Survey on Urolithiasis Treatment and Patient Satisfaction

PURPOSE

We created an Internet-based survey of patients treated for urolithiasis to evaluate for trends in treatment, outcome, and patient satisfaction and to establish internet surveys as a feasible medium for future research of patient urolithiasis treatment experiences.

MATERIALS AND METHODS

We used the website "kidneystoners.org" to disseminate the online survey, which queried respondents on treatment type, outcome, and satisfaction. Patient satisfaction was correlated with treatment type and outcome. Chi-square and analysis of variance tests were used to compare responses between treatment types.

RESULTS

Four hundred forty-three respondents completed the survey. The majority (46%) were treated ureteroscopically, followed by extracorporeal shock wave lithotripsy (SWL, 25%) and percutaneous nephrolithotomy (7%). Other treatments included spontaneous passage (13%), medical expulsive therapy (7%), and home remedies (2%). Sixty-four percent of respondents deemed their treatment "successful," while 36% reported their treatment as either "partially successful" or "unsuccessful." Unsuccessful treatment was more likely for SWL (17%) and home remedies (14%) (p=0.002). Most respondents (52%) reported being either satisfied or very satisfied with their treatment choice. Satisfaction did not vary significantly by treatment type, but was significantly associated with treatment success (mean satisfaction 3.8/5 for "successful" vs 1.9/5 for "unsuccessful" treatment; p<0.0001).

CONCLUSION

Use of the Internet allows rapid gathering of patient information from a large geographic distribution. Our survey is consistent with previous studies in demonstrating an increased use of ureteroscopy to treat both renal and ureteral calculi. In general, patients are satisfied with treatment outcomes despite a large percentage of people reporting needing to have secondary procedures.

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.

A new era: performance and limitations of the latest models of flexible ureteroscopes

OBJECTIVE

To comparatively study 3 of the latest models of flexible ureteroscopes using both subjective and objective parameters.

MATERIALS AND METHODS

Three models of flexible ureteroscopes (Karl Storz Flex-Xc, Olympus URF-Vo, and Wolf Cobra) were evaluated during 90 procedures. For each model, 20 procedures were therapeutic for pyelocaliceal lithiasis and 10 were diagnostic. The maneuverability and visibility were scored and compared, and the irrigation flow and maximal deflection were measured in an ex vivo setting, with an empty working channel and with accessory instruments in place. Instrument durability was also reviewed.

RESULTS

All models demonstrated good maneuverability, with a slight advantage for the Flex-Xc. During the diagnostic procedures, failure to access the entire pyelocaliceal system occurred in 2 cases with the URF-Vo, both because of a thin caliceal infundibulum, and in 1 case with the Cobra, because of complex caliceal architecture. Regarding visibility, although the performance of the digital models was relatively similar, the fiberoptic Cobra achieved a lower score. Loss of deflection and irrigation when using the various ancillary instruments was similar for all 3 endoscopes, but the Cobra offered supplementary flow through a secondary channel. The mean deflection loss was 5% for the URF-Vo, 9% for the Flex-Xc, and 10% for the Cobra. The visual quality of the 2 digital models remained unchanged during the study; however, in the fiberoptic ureteroscope, 58 optic fibers were broken.

CONCLUSION

The latest models of flexible ureteroscopes have proved to be effective instruments for upper urinary tract endoscopic interventions. There is still room for improvement, already made possible by the technological advances.

The new Olympus digital flexible ureteroscope (URF-V): Initial experience

Objective:

Flexible ureterorenoscopes (FURSs) are considered important additions to urology armamentarium. One of the technical drawbacks is the poor optic image provided by fiberoptic endoscope as well as the fragility of this conventional fiberoptic endoscope. This study aim is to evaluate practical performances and functional durability of the new Olympus digital flexible ureteroscope (ODF-URS) (URF-V) in a single center clinical setting.

Materials and Methods:

A number of 60 diagnostic and therapeutic procedures were performed over a period of 6 months in a single center (Tenon University Hospital), using a single ODF-URS (URF-V). This device provided a 275° maximal down-deflection (MDD) and 180° maximal up-deflection (MUD).

Results:

ODF-URS (URF-V) was used for a total time of 90 h and 30 min, with average time duration of 90.5 min per procedure. After 60 procedures, MDD decreased from 275° to 217°, while the MUD decreased from 180° to 161°. During six procedures (10%), URF-V failed to access inferior calyx due to a narrow lower calyx infundibulum.

Conclusion:

New ODF-URS (URF-V) is a reliable and durable device, with a good success rate and improved functional parameters. It is a superior device compared to predecessor generations of conventional fiberoptic endoscopes for the light source and the image quality; however, randomized comparative studies are necessary to evaluate performances and durability of this device.

Ureteroscopic retrograde intrarenal surgery after previous open renal stone surgery: initial experience

The management of renal calculi following previous open surgery represents a challenge for urologists. The aim of this study is to evaluate the outcomes and safety of ureteroscopic laser retrograde intrarenal surgery (RIRS) for renal calculi following prior open renal surgery. The charts of 53 patients who underwent RIRS for renal calculi following prior open surgery for urolithiasis were reviewed. Both flexible and semi-rigid ureteroscopes were utilized together with holmium: YAG laser for stone disintegration. Intravenous urography, computed tomography (CT) and ultrasound were used to evaluate the patient, perioperatively. Stone size ranged from 5 to 32 mm (mean 14.3 mm). The mean operative time was 86 min (20-130). The overall stone-free rate was 92.4%. The overall stone-free rates after one and two-procedures were 79.2% (42 cases) and 92.4% (49 cases), respectively. Four patients (7.5%) had larger residual fragments, 2 (3.8%) of them underwent SWL, and 2 (3.8%) cases were followed up conservatively. Major complications were reported in two patients (3.8%). Stone analysis revealed calcium oxalate in 39 patients, uric acid in 5, calcium phosphate in 4, struvite in 3, and cystine in 2 cases. Ureteroscopic retrograde intrarenal surgery for renal calculi following prior open renal surgery was a minimally invasive, safe procedure with a high success rate. It is a viable alternative for PNL in managing recurrent renal calculi efficiently.

Conventional fiberoptic flexible ureteroscope versus fourth generation digital flexible ureteroscope: a critical comparison

BACKGROUND AND PURPOSE

Development of flexible renoureteroscopy had a significant impact on the diagnosis and management of upper urinary tract pathology. The aim of our study was to compare the performances of a fiberoptic flexible ureteroscope (FFU) with those of a digital flexible ureteroscope (DFU).

MATERIAL AND METHODS

We compared the maneuverability, visibility, and fragility of a Storz 11274AA FFU and of an Olympus URF-Vo DFU. In 44 diagnostic retrograde procedures (22 with FFU and 22 with DFU), the maneuverability and visibility were evaluated with a score ranging from 1 to 5. The success of the inferior calix approach, maximal deflection, irrigation flow, and the endoscopes' fatigability were also compared.

RESULTS

FFU and DFU received mean scores of 3.64 vs 4.27 for maneuverability and 3.27 vs 4.68 for visibility. In four cases, acute infundibulopelvic angle and long infundibulum prevented the inferior calix approach with FFU. In two cases, the approach of the narrow infundibulum was impossible using DFU. The normal/pressure irrigation flow through FFU and DFU was 54/144 vs 60/150 mL/min with an empty working channel, decreasing to almost 0 mL/min with 3F instruments inserted. The maximal deflection loss of FFU and DFU ranged between 8% to 50.6% vs 0% to 21.1%, depending on the accessory instrument inserted through the working channel. After 22 procedures, the deflection loss was 10 degrees for the FFU and 0 degrees for the DFU.

CONCLUSIONS

DFU proved to have superior maneuverability and visibility, which may translate into improved performances. The larger tip of the DFU may decrease its accessibility, especially in narrow segments of the upper urinary tract.

Staged retrograde endoscopic lithotripsy as alternative to PCNL in select patients with large renal calculi

BACKGROUND AND PURPOSE

Percutaneous nephrolithotomy (PCNL) is currently the gold standard for management of large renal calculi. PCNL is associated, however, with a higher complication rate, degree of risk, and longer recovery period compared with ureteroscopy. In a selected group of patients who were not ideal candidates for PCNL because of extenuating health factors, a staged retrograde endoscopic approach was used to manage upper urinary tract calculi.

METHODS

We conducted a retrospective review of 23 patients (selected because of comorbidities, obesity, anatomy, and previous treatment failure as poor candidates for PCNL) who underwent staged retrograde endoscopic lithotripsy to manage upper urinary tract calculi. Lithotripsy was based on the application of small-diameter fiberoptic ureteroscopes and the holmium laser. Successful therapy was defined as total fragmentation of stone burden on repeated imaging. Data were analyzed using descriptive statistics.

RESULTS

Of the 468 patients who underwent ureteroscopy at our institution from 2003 to 2006, 23 patients (52% men, 57.70 +/- 11.44 years of age) were treated with retrograde endoscopic procedures for upper urinary tract calculi (52.2% lower pole). Stone burden at the initial procedure was 2.13 +/- 2.34 stones with a total linear length of 30.91 +/- 14.28 mm and an estimated total stone volume of 12,040.78 +/- 11101.54 cc (median value, 7,234.00 cc). There were no intraoperative complications; three patients were admitted postoperatively for observation. Ten 43.5%) patients (progressed to second-stage procedures (34.6 +/- 10.8 days apart). After repeated imaging, 73.9% of patients were stone free (88% lower pole), and 8.7% progressed to further intervention. Total linear stone length <4 cm and estimated calculus volume > or =15,000 cc predicted treatment failure (40%, 42.9%).

CONCLUSIONS

Percutaneous methods of managing renal stones have an increased rate of complications compared with ureteroscopy. In patients with complex medical histories, upper urinary tract calculi <4 cm can be safely and effectively managed using a staged retrograde endoscopic approach.

Anuric renal failure after same-session bilateral atraumatic flexible ureteroscopy

We report the first known case of anuric renal failure after same-session bilateral atraumatic flexible ureteroscopy for renal calculi. Although, there is no consensus about stenting patients who undergo same-session bilateral ureteroscopy due to the lack of prospective randomized studies; strong consideration should be given to stenting the ureter at least one side to avoid this complication.

Retrograde intrarenal surgery as second-line therapy yields a lower success rate

BACKGROUND AND PURPOSE

Retrograde intrarenal surgery (RIRS) is a recent addition to the treatment options for renal calculi. Therefore, the indications, as well as the predictors of success, are still being studied. Herein, we report a retrospective comparison of RIRS performed as the primary treatment and as second-line therapy, mostly after shockwave lithotripsy (SWL) failure.

PATIENTS AND METHODS

Between October 2001 and August 2004, 93 patients underwent RIRS (11% of all ureteroscopies), all by the same surgeon. Patients were divided into two groups: group 1 (n = 42) consisted of patients undergoing RIRS as a first-line modality and group 2 (n = 51) of those having RIRS as secondline therapy. The indications for RIRS in group 1 were renal calculi with prior placement of a double-J stent (30%), renal + ureteral stone (25%), pushback of ureteral stone during ureteroscopy (22%), a radiolucent stone (8%), coagulopathy, and abnormal renal anatomy. In group 2, the patients were initially treated by SWL (92%) or percutaneous nephrolithotomy. The groups did not differ significantly in demographic characteristics, mean stone size (9.5 and 8.7 mm, respectively), or stone location (in both 60% in the lower pole). The variables analyzed were operating time, complications, length of hospitalization, and stone-free rate.

RESULTS

The overall stone-free rate was 73%. However, the stone-free rate was significantly higher in group 1 than in group 2: 80% v 67%, respectively. A higher complication rate and longer hospitalization were noted in group 2, although the difference was not statistically significant.

CONCLUSIONS

When RIRS is performed after failed SWL, it has a lower success rate and may be associated with a higher morbidity rate than if it is performed as first-line therapy. These results suggest that the success rate of RIRS may be influenced by the same negative factors that reduce SWL success. Therefore, if a patient fails SWL, careful consideration should be given to the best second-line therapy comparing RIRS with percutaneous stone removal.

Kidney stones: pathophysiology and medical management

The formation of stones in the urinary tract stems from a wide range of underlying disorders. That clinicians look for the underlying causes for nephrolithiasis is imperative to direct management. There are many advances in genetics, pathophysiology, diagnostic imaging, medical treatment, medical prevention, and surgical intervention of nephrolithiasis. Here, I provide a brief general background and focus mainly on pathophysiology and medical treatment of kidney stones. Although important advances have been made in understanding nephrolithiasis from single gene defects, the understanding of polygenetic causes of kidney stones is still largely elusive. A substantial proportion of data that resulted in new methods of treatment and prevention, which can be empirical or definitive, has focused on urinary luminal chemical composition of the precipitating solutes. Manipulation of inhibitors and epithelial factors is important and needs further investigation. Advances in the management of nephrolithiasis depend on combined efforts of clinicians and scientists to understand the pathophysiology.