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

Sarwar Noori Mahmood, Hewa Toffeq, Saman Fakhralddin, Sarwar Noori Mahmood, Hewa Toffeq, Saman Fakhralddin

Abstract

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.

Keywords: Fluoroless retrograde intrarenal surgery; Renal stone; Retrograde intrarenal surgery; Sheathless flexible ureterorenoscopy.

© 2020 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V.

Figures

Figure 1
Figure 1
Stone-free rate according to the stone size.
Figure 2
Figure 2
Incidence of complication according to the stone size.

References

    1. Wendt-Nordahl G., Mut T., Krombach P., Michel M.S., Knoll T. Do new generation flexible ureterorenoscopes offer a higher treatment success than their predecessors? Urol Res. 2011;39:185–188.
    1. Bozkurt O.F., Resorlu B., Yildiz Y., Can C.E., Unsal A. Retrograde intra-renal surgery versus percutaneous nephrolithotomy in the management of lower-pole renal stones with a diameter of 15 to 20 mm. J Endourol. 2011;25:1131–1135.
    1. Preminger G.M., Tiselius H.G., Assimos D.G., Alken P., Buck C., Gallucci M. 2007 guideline for the management of ureteral calculi. J Urol. 2007;178:2418–2434.
    1. Rajamahanty S., Grasso M. Flexible ureteroscopy update: indications, instrumentation and technical advances. Indian J Urol. 2008;24:532–537.
    1. Lim S.H., Jeong B.C., Seo S.I., Jeon S.S., Han D.H. Treatment outcomes of retrograde intrarenal surgery for renal stones and predictive factors of stone-free. Korean J Urol. 2010;51:777–782.
    1. Resorlu B., Unsal A., Gulec H., Oztuna D. A new scoring system for predicting stone-free rate after retrograde intrarenal surgery: the “resorlu-unsal stone score”. Urology. 2012;80:512–518.
    1. Cansino Alcaide J.R., Reinoso Elbers J., López Sánchez D., Pérez González S., Rodriguez, Aguilera Bazán A. Flexible ureterorenoscopy (URS): technique and results. Arch Esp Urol. 2010;63:862–870.
    1. Schoenthaler M., Wilhelm K., Katzenwadel A., Ardelt P., Wetterauer U., Traxer O. Retrograde intrarenal surgery in treatment of nephrolithiasis: is a 100% stone-free rate achievable? J Endourol. 2012;26:489–493.
    1. Shah D.J., Sachs R.K., Wilson D.J. Radiation-induced cancer: a modern view. Br J Radiol. 2012;85:1166–1173.
    1. Berrington de Gonzalez A., Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet. 2004;363:345–351.
    1. Kourambas J., Byrne R.R., Preminger G.M. Does a ureteral access sheath facilitate ureteroscopy? J Urol. 2001;165:789–793.
    1. Johnson G.B., Portela D., Grasso M. Advanced ureteroscopy: wireless and sheathless. J Endourol. 2006;20:552–555.
    1. Traxer O., Thomas A. Prospective evaluation, and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol. 2012;189:580–584.
    1. Lallas C.D., Auge B.K., Raj G.V., Santa-Cruz R., Madden J.F., Preminger G.M. Laser Doppler flowmetric determination of ureteral blood flow after ureteral access sheath placement. J Endourol. 2002;16:583–590.
    1. Hyams E.S., Munver R., Bird V.G., Uberoi J., Shah O. Flexible ureterorenoscopy and holmium laser lithotripsy for the management of renal stone burdens that measure 2 to 3 cm: a multi-institutional experience. J Endourol. 2010;24:1583–1588.
    1. Xu Y., Min Z., Wan S.P., Nie H., Duan G. Complications of retrograde intrarenal surgery classified by the modified Clavien grading system. Urolithiasis. 2018;46:197–202.
    1. Rassweiler J.J., Renner C., Eisenberger F. The management of complex stones. BJU Int. 2000;86:919–928.
    1. Geraghty R.M., Aboumarzouk O.M., Rai B., Somani B.K. Evidence for ureterorenoscopy and laser fragmentation (URSL) for large renal stones in the modern era. Curr Urol Rep. 2015;16:1–6.
    1. Giusti G., Proietti S., Peschechera R., Taverna G., Sortino G., Cindolo L. Sky is no limit for ureteroscopy: extending the indications and special circumstances. World J Urol. 2015;33:257–273.
    1. Breda A., Ogunyemi O., Leppert J.T., Lam J.S., Schulam P.G. Flexible ureteroscopy and laser lithotripsy for single intrarenal stones 2 cm or greater—is this the new frontier? J Urol. 2008;179:981–984.
    1. Takazawa R., Kitayama S., Tsujii T. Appropriate kidney stone size for ureteroscopic lithotripsy: when to switch to a percutaneous approach. World J Nephrol. 2015;4:111–117.
    1. Akman T., Binbay M., Ozgor F., Ugurlu M., Tekinarslan E., Kezer C. Comparison of percutaneous nephrolithotomy and retrograde flexible nephrolithotripsy for the management of 2–4 cm stones: a matched-pair analysis. BJU Int. 2012;109:1384–1389.
    1. Hyams E.S., Shah O. Percutaneous nephrolithotomy versus flexible ureteroscopy/holmium laser lithotripsy: cost and outcome analysis. J Urol. 2009;182:1012–1017.
    1. Türk C., Knoll T., Petrik A., Sarica K., Seitz C., Straub M. European association guidelines; 2012. Guidelines on urolithiasis.
    1. Smith Rd, Patel A. Impact of flexible ureterorenoscopy in current management of nephrolithiasis. Curr Opin Urol. 2007;17:114–119.
    1. Beiko D.T., Denstedt J.D. Advances in ureterorenoscopy. Urol Clin N Am. 2007;34:397–408.
    1. Riley J.M., Stearman L., Troxel S. Retrograde ureteroscopy for renal stones larger than 2.5 cm. J Endourol. 2009;23:1395–1398.
    1. Cocuzza M., Colombo J.R., Jr., Ganpule A., Turna B., Cocuzza A., Dhawan D. Combined retrograde flexible ureteroscopic lithotripsy with holmium YAG laser for renal calculi associated with ipsilateral ureteral stones. J Endourol. 2009;23:253–257.
    1. Mahesh M. Fluoroscopy: patient radiation exposure issues. RadioGraphics. 2001;21:1033–1045.
    1. National Research Council . National Academies Press; Washington DC: 2006. Health risk from exposure to low levels of ionizing radiation: BEIR VII phase 2; pp. 7–8.
    1. Krupp N., Bowman R., Tenggardjaja C., Jellison F., Hill B., Ebrahimi K. Fluoroscopic organ and tissue-specific radiation exposure by sex and body mass index during ureteroscopy. J Endourol. 2010;24:1067–1072.
    1. Traxer O. Flexible ureterorenoscopic management of lower-pole stone: does the scope make the difference? J Endourol. 2008;22:1847–1850.
    1. Hsi R.S., Harper J.D. Fluoroless ureteroscopy: zero-dose fluoroscopy during ureteroscopic treatment of urinary-tract calculi. J Endourol. 2013;27:432–437.
    1. Brisbane W., Smith D., Schlaifer A., Anderson K., Baldwin D.D. Fluoro-less ureteral stent placement following uncomplicated ureteroscopic stone removal: a feasibility study. Urology. 2012;80:766–770.
    1. Tepeler A., Armagan A., Akman T., Sılay M.S., Akçay M., Başıbüyük I. Is fluoroscopic imaging mandatory for endoscopic treatment of ureteral stones? Urology. 2012;80:1002–1006.
    1. Greene D.J., Tenggadjaja C.F., Bowman R.J., Agarwal G., Ebrahimi K.Y., Baldwin D.D. Comparison of a reduced radiation fluoroscopy protocol to conventional fluoroscopy during uncomplicated ureteroscopy. Urology. 2011;78:286–290.
    1. Kirac M., Tepeler A., Guneri C., Kalkan S., Kardas S., Armagan A. Reduced radiation fluoroscopy protocol during retrograde intrarenal surgery for the treatment of kidney stones. Urol J. 2014;11:1589–1594.
    1. Çimen H.İ., Halis F., Sağlam H.S., Gökçe A. Fluoroscopy-free technique is safe and feasible in retrograde intrarenal surgery for renal stones. Turk J Urol. 2017;43:309–312.
    1. Aboutaleb H. Fluoroscopy free flexible ureteroscopy with holmium: yttrium-aluminium-garnet laser lithotripsy for removal of renal calculi. Arab J Urol. 2016;14:123–130.
    1. Peng Y., Xu B., Zhang W., Li L., Liu M., Gao X. Retrograde intrarenal surgery for the treatment of renal stones: is fluoroscopy-free technique achievable? Urolithiasis. 2015;43:265–270.
    1. Turna B., Stein R.J., Smaldone M.C., Santos B.R., Kefer J.C., Jackman S.V. Safety and efficacy of flexible ureterorenoscopy and holmium: YAG lithotripsy for intrarenal stones in anticoagulated cases. J Urol. 2008;179:1415–1419.
    1. L'esperance J.O., Ekeruo W.O., Scales C.D., Jr., Marguet C.G., Springhart W.P., Maloney M.E. Effect of ureteral access sheath on stone-free rates in patients undergoing ureteroscopic management of renal calculi. Urology. 2005;66:252–255.
    1. Stern J.M., Yiee J., Park S. Safety and efficacy of ureteral access sheaths. J Endourol. 2007;21:119–123.
    1. Bach C., Nesar S., Kumar P., Goyal A., Kachrilas S., Papatsoris A. The new digital flexible ureteroscopes: ‘size does matter’—increased ureteric access sheath use! Urol Int. 2012;89:408–411.
    1. Takazawa R., Kitayama S., Tsujii T. Successful outcome of flexible ureteroscopy with holmium laser lithotripsy for renal stones 2 cm or greater. Int J Urol. 2012;19:264–267.
    1. Grasso M., Ficazzola Retrograde ureteropyeloscopy for lower pole caliceal calculi. J Urol. 1999;162:1904–1908.
    1. Mariani A.J. Combined electrohydraulic and holmium: YAG laser ureteroscopic nephrolithotripsy of large (greater than 4 cm) renal calculi. J Urol. 2007;177:168–173.
    1. Xiao Y., Li D., Chen L., Xu Y., Zhang D., Shao Y. The R.I.R.S. scoring system: an innovative scoring system for predicting stone-free rate following retrograde intrarenal surgery. BMC Urol. 2017;17:105. doi: 10.1186/s12894-017-0297-0.
    1. Bosio A., Alessandria E., Vitiello F., Dalmasso E., Agosti S., Pizzuto G. Variables affecting flexible ureteroscopy stone-free rates. Eur Urol Suppl. 2017;16:e2542. doi: 10.1016/S1569-9056(17)31674-3.
    1. Grasso M., Conlin M., Bagley D. Retrograde ureteropyeloscopic treatment of 2 cm or greater upper urinary tract and minor staghorn calculi. J Urol. 1998;160:346–351.
    1. Sofer M., Watterson J.D., Wollin T.A., Nott L., Razvi H., Denstedt J.D. Holmium:YAG laser lithotripsy for upper urinary tract calculi in 598 patients. J Urol. 2002;167:31–34.
    1. Aboumarzouk O.M., Somani B., Monga M. Safety and efficacy of ureteroscopic lithotripsy for stone disease in obese patients: a systematic review of the literature. BJU Int. 2012;110:E374–E380. doi: 10.1111/j.1464-410X.2012.11086.x.
    1. Ising S., Labenski H., Baltes S., Khaffaf A., Thomas C., Wiesner C. Flexible ureterorenoscopy for treatment of kidney stones: establishment as primary standard therapy in a tertiary stone center. Urol Int. 2015;95:329–335.
    1. Türk C., Knoll T., Petrik A., Sarica K., Skolarikos A., Straub M. European Association Guidelines; 2014. Guidelines on urolithiasis.
    1. Rehman J., Monga M., Landman J., Lee D.I., Felfela T., Conradie M.C. Characterization of intrapelvic pressure during ureteropyeloscopy with ureteral access sheaths. Urology. 2003;61:713–718.
    1. Suh L.K., Rothberg M.B., Landman J., Katsumi H., Gupta M. Intrarenal pressures generated during deployment of various antiretropulsion devices in an ex vivo porcine model. J Endourol. 2010;24:1165–1168.
    1. Zhong W., Leto G., Wang L., Zeng G. Systemic inflammatory response syndrome after flexible ureteroscopic lithotripsy: a study of risk factors. J Endourol. 2015;29:25–28.
    1. McAleer I.M., Kaplan G.W., Bradley J.S., Carroll S.F. Staghorn calculus endotoxin expression in sepsis. Urology. 2002;59:601.
    1. Wang Q., Liao W., Yang S., Song C., Xiong Y., Meng L. Retrospectively analysis of risk factors for systemic inflammatory response syndrome following retrograde intrarenal stone surgery. Int J Clin Exp Med. 2016;9:8327–8333.
    1. McAleer I.M., Kaphn G.W., Bradley J.S., Carroll S.F., Griffith D.P. Endotoxin content in renal calculi. J Urol. 2003;169:1813–1814.
    1. Traxer O., Wendt-Nordahl G., Sodha H., Rassweiler J., Meretyk S., Tefekli A. Differences in renal stone treatment outcomes for patients treated either with or without the support of a ureteral access sheath: the Clinical Research Office of the Endourological Society Ureteroscopy Global Study. World J Urol. 2015;33:2137–2144.
    1. Skolarikos A., Gross A.J., Krebs A., Unal D., Bercowsky E., Eltahawy E. Outcomes of flexible ureterorenoscopy for solitary renal stones in the CROES URS global study. J Urol. 2015;194:137–143.
    1. Geraghty R.M., Ishii H., Somani B.K. Outcomes of flexible ureteroscopy and laser fragmentation for treatment of large renal stones with and without the use of ureteral access sheaths: results from a university hospital with a review of literature. Scand J Urol. 2016;50:216–219.
    1. Sountoulides P., Metaxa L., Cindolo L. Is computed tomography mandatory for the detection of residual stone fragments after percutaneous nephrolithotomy? J Endourol. 2013;27:1341–1348.
    1. Macejko A., Okotie O.T., Zhao L.C., Liu J., Perry K., Nadler R.B. Computed tomography-determined stone-free rates for ureteroscopy of upper-tract stones. J Endourol. 2009;23:379–382.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera