|Year : 2021 | Volume
| Issue : 4 | Page : 336-339
Bilateral same session renal stone surgery tolerance and complications
Abdulmalik Addar1, Ahmed Aljuhayman2, Yahya Ghazwani3, Abdullah Al Khayal3, Ahmed Alasker3, Esteban Emiliani4, Saeed Bin Hamri5
1 Department of Urology, McGill University Health Center, McGill University, Montreal, QC, Canada
2 Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia
3 Division of Urology, Department of Surgery, Ministry of the National Guard - Health Affairs; King Abdullah International Medical Research Center; College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
4 PETRA-UROGROUP, Riyadh, Saudi Arabia; Endourology and Urolithiasis Unit, Fundacio Puigvert, Barcelona, Spain
5 Division of Urology, Department of Surgery, Ministry of the National Guard - Health Affairs; King Abdullah International Medical Research Center; College of Medicine, King Saud bin Abdulaziz University for Health Sciences; PETRA-UROGROUP, Riyadh, Saudi Arabia
|Date of Submission||08-Aug-2020|
|Date of Acceptance||25-Jan-2021|
|Date of Web Publication||02-Sep-2021|
Dr. Saeed Bin Hamri
2682 Prince Muteb Bin Abdulah Street, Ar Rimayah, Riyadh 14611
| Abstract|| |
Introduction: The prevalence rate of upper urinary tract calculi in Saudi Arabia is one of the highest globally. Bilateral renal stone management is an option but is still controversial.
Methodology: The study was a retrospective study, including 31 patients with bilateral renal or ureteric stones who underwent bilateral same-session ureterorenoscopy (BSS-URS). The data collected included age, gender, body mass index (BMI), stone burden bilaterally, operative time bilaterally, hospital stay, stone location, type of anesthesia, stone history, renal anomaly as well as pre- and postoperative JJ stenting. In addition, data related to complications (ureteric injury, renal failure, urinary tract infection, pain requiring an emergency department visit within 1 week of the procedure), the stone-free rate (defined as £ 3 mm asymptomatic stone fragment identified with computed tomography Kidney, Ureter and Bladder 3 months after surgery was also collected. The data were collected from the electronic patient record system, entered in an Excel spreadsheet, and descriptive analysis was done.
Results: In total, 31 patients were included, with the majority (80.6%, n = 25) male. The mean age was 41.6 years, the mean BMI 28.7 ± 5.59, the mean operative time for each renal unit 46.53 ± 25.69 min, and the mean hospital stay 17.87 ± 8.43 h. The majority (96.7%, n = 30) received general anesthesia. Less than half (40.3%, n = 25) of the renal units had stones in multiple calyces and the majority (90.3%, n = 56) of the renal units were stone free at the 3-month follow-up. A small proportion (3.2%, n = 2) of the renal units were polycystic. Prestenting was documented in 40.3% (n = 25) of the renal units and the majority (95.2%, n = 59) were stented postoperatively.
Conclusion: BSS-URS is a safe and a highly effective management option for bilateral renal stones.
Keywords: Endourology, lithiasis, lithotripsy, ureteroscopy
|How to cite this article:|
Addar A, Aljuhayman A, Ghazwani Y, Al Khayal A, Alasker A, Emiliani E, Hamri SB. Bilateral same session renal stone surgery tolerance and complications. Urol Ann 2021;13:336-9
|How to cite this URL:|
Addar A, Aljuhayman A, Ghazwani Y, Al Khayal A, Alasker A, Emiliani E, Hamri SB. Bilateral same session renal stone surgery tolerance and complications. Urol Ann [serial online] 2021 [cited 2021 Nov 30];13:336-9. Available from: https://www.urologyannals.com/text.asp?2021/13/4/336/325511
| Introduction|| |
Urolithiasis is a disease with the global health problem. In the recent past, the prevalence and incidence of urinary tract stones increased with a significant number of patients presenting with bilateral stones., The treatment options, particularly retrograde intrarenal surgeries, have evolved extensively, though the management of bilateral stones remains controversial due to safety concerns.
Extracorporeal Shock Wave Lithotripsy (ESWL) is the least invasive intervention with a reasonable success rate, however in cases of multiple or high burden stones, the success rate is reduced and secondary procedures, such as Percutaneous Nephrolithotomy (PCNL) and Flexible Ureterorenoscopy (FURS) may be required. Staged and simultaneous bilateral PCNL are both feasible options for upper urinary tract stones. Although performing PCNL bilaterally in the same operation saves patients from multiple operative procedures, reduces the length of hospital stay, and accelerates their recovery, it is of limited use in cases with concurrent renal and ureteral stones. FURS has an improved success rate compared to ESWL, is less invasive than PCNL and it is possible to reach both ureteral and renal stones. However, bilateral same-session ureterorenoscopy (BSS-URS) is not widely accepted due to the potential risk of bilateral ureteral injuries which could cause significant morbidity.
Saudi Arabia has one of the highest rates of urinary tract stones, attributed to various environmental and nutritional factors. If BSS-URS is proven to be a feasible and safe management option for bilateral renal stones, it can be implemented in practice to reduce cost, working days lost, and the need for subsequent interventions. The aim of this study is to evaluate the outcome and safety of BSS-URS in the management of bilateral renal stones.
| Methodology|| |
This was a retrospective study, including 31 patients with bilateral renal or ureteric stones, 62 renal units, who underwent BSS-URS at King Abdulaziz Medical City in Riyadh from June 2016 till June 2018.
The data collected included age, gender, body mass index (BMI), stone burden bilaterally, operative time bilaterally, hospital stay, stone location, type of anesthesia, stone history, renal anomaly as well as pre-and postoperative JJ stenting. In addition, data related to complications (ureteric injury, renal failure, urinary tract infection [UTI], pain requiring an emergency department visit within 1 week of the procedure) and the stone free rate defined as < 3mm asymptomatic stone fragment identified with computed tomography kidney, ureter, and bladder (CT KUB) 3 months after surgery was also collected. A renal US was done 9 months post-procedure to rule out hydronephrosis. The data were collected, entered in an Excel spreadsheet, and analyzed with descriptive statistics.
We used a Storz Flex X2 flexible ureteroscope for all the patients with a 10/12F ureteric access sheath. All patients received prophylactic antibiotics on the induction of the anesthesia. The patients were discharged home as per departmental protocol for postoperative analgesia and given an appointment for removal of the JJ stent 2 weeks later.
| Results|| |
In total, 31 patients were included in the study with the majority (80.6%, n = 25) male. The mean age was 41.6 ± 11.81 years, the mean BMI 28.7 ± 5.59 kg/m2 [Table 1], the mean operative time for each renal unit 46.53 ± 25.69 min [Table 2]. The majority (96.7%, n = 30) was done under general anesthesia. Less than half (40.3%, n = 25) of the renal units had stones in multiple calyces, and the majority (90.3%, n = 56) [Table 3] of the renal units were stone free at the 3-month follow-up. A small proportion of renal units (3.2%, n = 2) were polycystic. The mean hospital stay was 17.87 ± 8.43 h [Table 1]. No patient had hydronephrosis at the 9-month follow-up renal US. Prestenting was done in 40.3% (n = 25) of the renal units with the majority (95.2%, n = 59) stented postoperatively [Table 2]. Two patients (3.45%) developed a UTI postoperatively which required antibiotic treatment as an outpatient. The mean fluoroscopy time per unit was 57.6 s with a maximum 135 s.
| Discussion|| |
FURS is a huge technological advancement developed for the management of renal stones. Since it was introduced, ureteroscopy was used to treat only distal ureteric stones. Henceforth, recently it is used with all types of stones including renal and proximal ureteric stones due to technological advances in scopes and the maneuvers used. The goal in the management of urolithiasis is to render patients stone-free, using the least invasive procedure with the lowest complications rate, and financially cost-effective. Bilateral ureteroscopy has a stone-free rate of more than 85%, saving patients the need for subsequent procedures., In the current study, the stone-free rate was 90.3%, which agrees with other reported series.
A stone-free rate is defined as £3 mm asymptomatic stone fragment identified with CT KUB 3 months after surgery. This is a matter of controversy as some authors define stone free as zero fragments or residual on noncontrast CT KUB. It is difficult to justify the origin of our criteria. Huang et al., in a retrospective analysis with 25 patients who underwent BSS-URS for multiple intrarenal stones, reported a stone-free rate of 72% after the first session and 92% after the second session. They defined stone free as the absence of fragments <1 mm using an ultrasound scan. In the current study, 90.3% (n = 56) of the renal units were deemed stone free at the 3-month follow-up with CT scan.
A recent systematic review done by Geraghty et al. explored the use of BSS-URS versus staged therapy and concluded the outcomes identical, with the additional advantage for BSS-URS of reduced cost, hospital stay, and operative time. In terms of complications, BSS-URS had fewer complications than staged therapy.
Currently, new endourological modalities exist which has made BSS-URS a more feasible option. For example, ureteral access sheaths that reduce intrarenal pressure facilitates an easier introduction of the ureteroscope as well as removing the stone fragments. In addition, hard to reach stones can be fragmented and extracted more easily due to new innovations in laser and basket technologies.
The mean operative time per patient in the current study was approximately 90 min. A recent study published by Knipper et al. reported that a longer operative time may be associated with a higher complication rate which is true for minor complications. The rate of major complications is low regardless of the operative time.
This study has limitations. First, the sample size was small, the setting a specialized tertiary care hospital, and all BSS-URS procedures were done by a fellowship-trained endourologist which may affect the operative time and stone clearance rate. The same may not be applicable to nonfellowship trained urologists. Second, we did not compare the BSS-URS with staged therapy or the cost of such treatment. The current study is one of few studies related to BSS-URS but with a relatively large sample size. Follow-up was intermediate as all patients were followed up to 9 months with no significant complications, hydronephrosis, and the stone-free rate was high as (90%).
In conclusion, BSS-URS is a safe procedure with tolerable complications if done by an experienced endourologists. It is a judicious option, saving patients the inconvenience of subsequent procedures. With ureteroscopy being the most used procedure for urolithiasis management, it is crucial to find the best approach to achieve a stone-free status with the least number of sessions. BSS-URS has been proven to be a reasonable, safe option with low a complication rate and in selected patients, preferred above-staged therapy. We recommend randomized control trials to explore this novel approach in treating patients with bilateral renal stones compared with staged therapy including the financial aspects of both therapies.
This study was funded and supported by King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. Study approval number RC18/318/R.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Romero V, Akpinar H, Assimos DG. Kidney stones: A global picture of prevalence, incidence, and associated risk factors. Rev Urol 2010;12:e86-96.
Lee S, Koh L, Ng K, Ng F. 318 incidence of computed tomography (CT) detected urolithiasis: An update. European Urology Supplements 2013;12:e318-9.
Abe T, Akakura K, Kawaguchi M, Ueda T, Ichikawa T, Ito H, et al
. Outcomes of shockwave lithotripsy for upper urinary-tract stones: A large-scale study at a single institution. J Endourol 2005;19:768-73.
Silverstein AD, Terranova SA, Auge BK, Weizer AZ, Delvecchio FC, Pietrow PK, et al
. Bilateral renal calculi: Assessment of staged v synchronous percutaneous nephrolithotomy. J Endourol 2004;18:145-51.
Resorlu B, Unsal A, Ziypak T, Diri A, Atis G, Guven S, et al
. Comparison of retrograde intrarenal surgery, shockwave lithotripsy, and percutaneous nephrolithotomy for treatment of medium-sized radiolucent renal stones. World J Urol 2013;31:1581-6.
Robertson WG, Hughes H. Epidemiology of Urinary Stone Disease in Saudi Arabia. In: Ryall R, Bais R, Marshall VR, Rofe AM, Smith LH, Walker VR. (eds) Urolithiasis 2. Springer, Boston, MA 1994. https://doi.org/10.1007/978-1-4615-2556-1_174
Su LM, Sosa RE. Ureteroscopy and retrograde ureteral access. Walsh PC, Retik AB, Vaughan ED, Wein AJ, editors. Campbell's Urology. 8th
ed. Philadelphia, PA; WB Saunders: 2002: p. 3306-18.
Drake T, Ali A, Somani BK. Feasibility and safety of bilateral same-session flexible ureteroscopy (FURS) for renal and ureteral stone disease. Cent European J Urol 2015;68:193-6.
Huang Z, Fu F, Zhong Z, Zhang L, Xu R, Zhao X. Flexible ureteroscopy and laser lithotripsy for bilateral multiple intrarenal stones: Is this a valuable choice? Urology 2012;80:800-4.
Geraghty RM, Jones P, Somani BK. Simultaneous bilateral endoscopic surgery (SBES) for bilateral urolithiasis: The future? Evidence from a systematic review. Curr Urol Rep 2019;20:15.
Ghani KR, Wolf JS. What is the stone-free rate following flexible ureteroscopy for kidney stones? Nature Reviews Urology 2015;12:281-8.
Kourambas J, Byrne RR, Preminger GM. Does a ureteral access sheath facilitate ureteroscopy? J Urol 2001;165:789-93.
Preminger GM. Management of lower pole renal calculi: Shock wave lithotripsy versus percutaneous nephrolithotomy versus flexible ureteroscopy. Urol Res 2006;34:108-11.
Knipper S, Tiburtius C, Gross AJ, Netsch C. Is prolonged operation time a predictor for the occurrence of complications in ureteroscopy? Urol Int 2015;95:33-7.
[Table 1], [Table 2], [Table 3]