Retrograde Ureteroscopic Management of Large Renal Calculi: a Single Institutional Experience and Concise Literature Review
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JOURNAL OF ENDOUROLOGY Volume 32, Number 7, July 2018 ª Mary Ann Liebert, Inc. Pp. 603–607 DOI: 10.1089/end.2018.0069 Retrograde Ureteroscopic Management of Large Renal Calculi: A Single Institutional Experience and Concise Literature Review Kymora B. Scotland, MD, PhD,1 Benjamin Rudnick, MD,2 Kelly A. Healy, MD,3 Scott G. Hubosky, MD,2 and Demetrius H. Bagley, MD2 Abstract Introduction: Advances in flexible ureteroscope design and accessory instrumentation have allowed for more challenging cases to be treated ureteroscopically. Here, we evaluate our experience with ureteroscopy (URS) for the management of large renal calculi (‡2 cm) and provide a concise review of recent reports. Methods: A retrospective review was undertaken of all URS cases between 2004 and 2014 performed by the endourologic team at a single academic tertiary care institution. We identified patients with at least one stone ‡2 cm managed with retrograde URS. Stone size was defined as the largest linear diameter of the index stone. Small diameter flexible ureteroscopes were used primarily with holmium laser. Patient demographics, in- traoperative data, and postoperative outcomes were evaluated. Results: We evaluated 167 consecutive patients who underwent URS for large renal stones ‡2 cm. The initial reason for choosing URS included patient preference (29.5%), failure of other therapies (8.2%), anatomic con- siderations/body habitus (30.3%), and comorbidities (28.8%). Mean patient age was 55.5 years (22–84). The mean stone size was 2.75 cm with mean number of procedures per patient of 1.65 (1–6). The single session stone-free rate was 57.1%, two-stage procedure stone-free rate was 90.2% and three-stage stone-free rate was 94.0%. Access sheaths were used in 47% of patients. An association was identified between stone size and patient outcomes; smaller stones correlated with decreased number of procedures. Postoperative complications were minor. Conclusions: Single or multi-stage retrograde ureteroscopic lithotripsy is a safe and effective mode of surgical management of large renal calculi. Total stone burden is a reliable predictor of the need for a staged procedure and of stone-free rate. Keywords: ureteroscopy, nephrolithiasis, lithotripsy Downloaded by NCSU North Carolina State University from www.liebertpub.com at 01/09/19. For personal use only. Introduction renal insufficiency, and chronic obstructive pulmonary dis- ease (COPD) may be associated with an increased risk for enal calculi greater than 2 cm in diameter have his- these complications. Patients with bleeding diatheses or on Rtorically been treated with percutaneous nephrolithotomy strict anticoagulation may experience significant blood loss (PCNL), which continues to be recommended as per Ameri- with this surgery, making them poor candidates for PCNL can Urologic Association (AUA) guidelines.1 PCNL clear- while others would simply prefer less invasive treatment ance rates for these large stones range from 83% to 90%.2 options. Although technological modifications have led to the However, PCNL remains largely an inpatient procedure as- advent of the ‘‘mini-PCNL’’ with smaller access tracts (14– sociated with complications such as blood loss requiring 20F), complication rates have remained significant with up to transfusion, extravasation, and less commonly, sepsis and 2% of patients requiring transfusions and longer operative pleural or colonic injury.2,3 Comorbidities such as obesity, times when compared to standard PCNL.4 1Department of Urologic Sciences, University of British Columbia, Vancouver, Canada. 2Department of Urology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. 3Department of Urology, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York. All work done at Thomas Jefferson University Hospital. 603 604 SCOTLAND ET AL. Since the advent of the semirigid fiberoptic ureteroscope Table 1. Indications for Ureteroscopic Management and deflectable flexible ureteropyeloscope, retrograde litho- of Large Renal Calculi tripsy has long been described as a viable option for treatment of upper tract calculi.5,6 In recent years, flexible ureteroscopy No. of % of patients Reason for ureteroscopy patients (n = 167) (URS) with holmium laser lithotripsy has become a favorable management option for large renal calculi as the technology Anatomic considerations/body 20 12.0 of flexible ureteroscopes and endoscopic surgical technique habitus have continued to improve. Smaller endoscopes, increased Comorbiditiesa 19 11.4 endoscope flexibility, and holmium laser technology have Patient preference 17 10.2 Failure of other therapies 10 6.0 made retrograde management of large renal calculi an in- b creasingly appealing option for urologists and patients alike. Other 3 1.8 Indications for retrograde ureteroscopic treatment of these None indicated 99 59.3 stones include failed prior percutaneous therapy, hypermet- aIncluding bleeding diatheses, chronic anticoagulation. abolic syndrome, morbid obesity, chronic anticoagulation, bIncluded concern for urothelial malignancy, encrusted stent anatomic factors, and patient preference. In this study, we distally attached to a bladder stone, and recent subcapsular present a single institutional experience with retrograde URS hematoma. with laser lithotripsy for the management of large (>2 cm) renal stones. Evaluation of patient demographics revealed that 58.1% of patients were female (Table 2). There was no apparent dif- Patients and Methods ference in the presentation of patients with left-sided vs right- sided calculi. Mean stone size was 2.75 cm. The number of An Institutional Review Board approved retrospective procedures required for stone clearance was evaluated based analysis was performed of electronic medical records, oper- on stone size (Table 3). Stones that were 3 cm in diameter or ative notes, and anesthesia reports investigating patients presenting to this institution with large renal calculi over a 10-year period from 2004 to 2014. A total of 167 patients Table 2. Patient and Stone Demographics with at least one stone with diameter >2 cm were treated during this time. Stone size was determined using the largest Demographics diameter on coronal or axial view on computed tomography (CT) of the abdomen and pelvis. The method of assigning Age (mean, years) 55.5 size based on cumulative diameter of all stones was not used Gender in this study. Female 97 (58.1%) Male 70 (41.9%) Patients were administered perioperative intravenous an- tibiotics. Cystoscopy was performed under general anesthe- Laterality sia. Fluoroscopy and safety guidewires were used. A flexible Right 83 (49.7%) Left 80 (47.9%) ureteroscope was advanced to the renal pelvis and lithotripsy Bilateral 4 (2.4%) was performed using a Holmium laser fiber of size 200 or 365 lm depending on stone location. Holmium laser litho- Stone size Mean (cm) 2.75 tripsy was used in every case. Electrohydraulic lithotripsy Median (cm) 2.5 (EHL) was performed in an adjunctive fashion in a minority of cases. A 12/14F ureteral access sheath was used when Stone location Renal pelvis 72 (42.1%) deemed appropriate. Stone manipulation was undertaken Staghorn/multiple 60 (35.1%) using nitinol stone retrieval baskets. Calculus fragments were sent for analysis and ureteral stents were placed routinely. Poles Lower pole 22 (12.9%) Patients were considered to be stone free if a single fragment Upper pole 12 (7.0%) smaller than 3 mm remained after lithotripsy. Clearance was Downloaded by NCSU North Carolina State University from www.liebertpub.com at 01/09/19. For personal use only. Mid pole 5 (2.9%) confirmed visually in the operating room or with CT. If CT Stone compositiona was not performed, follow-up kidney, ureter, and bladder Mixed 45 (32.3%) radiograph (KUB) and ultrasound were completed as an Uric acid 24 (17.3%) outpatient with residual stone size measured using the KUB. Calcium oxalate 22 (15.8%) The patient data were evaluated for patient demographics, monohydrate (COM) intraoperative data, stone parameters, and patient outcomes. Apatite 22 (15.8%) Operative time was recorded as time from beginning to end of Calcium oxalate 9 (6.5%) anesthesia. Fisher’s exact test of independence with a two- dihydrate (COD) tailed p-value was performed to determine patient outcomes. Cystine 7 (5.0%) Struvite 6 (4.3%) Brushite 4 (2.9%) Results Access sheath used 128 (47%b) Patient risk factors for undergoing URS for management of Laser energy used (mean, kJ) 21.88 large renal stones included obesity, bilateral nephrolithiasis, aStone composition only available for 139/167 patients. cystinuria, and COPD. Reasons for choosing URS are bOne hundred twenty-eight procedures of 271 total stages had documented in Table 1. documented use of ureteral access sheaths. URETEROSCOPY FOR LARGE STONES 605 Table 3. Outcome Evaluation Based on Stone Size PCNL may pose a serious risk or in patients who prefer to undergo a less invasive but still effective modality for large Number of procedures stone management, URS is an ideal alternative. needed for clearance Stone Number of The recent AUA guidelines on surgical management of size (cm) patientsa 12‡3 stones recommend PCNL for renal calculi >2 cm in diameter in adults.1 However, URS is rapidly becoming an attractive 2–2.9 80 52 25 3 alternative. Recent studies have demonstrated that URS with ‡366302313holmium laser lithotripsy can be an effective alternative treatment option for these patients with reported clearance aRemaining patients did not completely clear their stone burden (see section ‘‘Discussion’’). rates ranging from 83% to 93% after an average of 1–2.4 procedures.10–14 Reported complication rates are low and larger required a greater number of procedures for stone most typically consist of postoperative fever, pain, and uri- clearance compared to stones that were <3 cm. This finding nary tract infection. A recent meta-analysis by Aboumarzouk was determined to be significant; patients with stone size and colleagues reported an overall complication rate of 10.1%, with major complications developing in 5.3% of pa- >3 cm were more likely to undergo more than one operative 15 procedure than those with stones of 2.9 cm or smaller tients.