Flexible Ureterorenoscopy under Spinal Anesthesia: Focus on Technique, Results, Complications, and Patients’ Satisfaction from a Large Series

<b><i>Introduction:</i></b> Although spinal anesthesia (SA) may reduce postoperative morbidity, most urologists perform flexible ureterorenoscopy (fURS) under general anesthesia (GA). The objective of our study is to provide technical details, results, complications, and patients’ satisfaction with fURS performed under exclusive SA. <b><i>Methods:</i></b> We analyzed all consecutive fURS performed under SA to treat renal stones from March 2011 to February 2017. Details of technique, operative time, outcomes, need for further treatments, complications, and patients’ satisfaction were evaluated. <b><i>Results:</i></b> Two hundred thirty-four fURS under SA were considered. SA was performed through L2-L3 vertebral interspace in 64.1%. Patients were discharged the same day of surgery. Mean stone burden was 13.5 ± 6.6 mm and mean operative time 76.9 ± 34.6 min. Single-procedure SFR was 69.7%. Further treatments were performed in 22.8%. 96.6% had no anesthesia-related complications. No Clavien-Dindo grade ≥ IIIb complications were noticed. 99.6% of patients were satisfied with SA. No cases of conversion from SA to GA occurred. <b><i>Conclusion:</i></b> fURS can be performed safely and efficiently under SA, taking into account a few details of the technique. Patients’ satisfaction with SA is very high, and complications are rare. Although SA is usually adopted in unfit patients for GA, it may be considered as a viable alternative in fit patients.

Impact of Preoperative Stenting on the Outcome of Flexible Ureterorenoscopy for Upper Urinary Tract Urolithiasis: A Systematic Review and Meta-Analysis

<b><i>Purpose:</i></b> This study aimed to investigate the effect of preoperative stenting (POS) on the perioperative outcomes of flexible ureterorenoscopy (fURS). <b><i>Materials and Methods:</i></b> A systematic review and meta-analysis was conducted based on the PRISMA statement. From the initially retrieved 609 reports, we excluded the ineligible studies at 2 stages. We only included studies that contained fURS patients with and without POS in the same report. Data of patients who underwent semirigid ureteroscope only were excluded from the analysis. The Newcastle-Ottawa Scale (NOS) system was applied for risk of bias assessment. <b><i>Results:</i></b> A total of 20 studies including 5,852 patients were involved. 48.5% of the patients had preoperative stent. Stone-free rate was significantly higher with prestenting; odds ratio (OR) was 1.98 (95% CI: 1.51–2.58) (<i>Z</i> = 5.02; <i>p</i> = 0.00001). It also displayed tendency toward lower complications; OR was 0.74 (95% CI: 0.52–1.05) (<i>Z</i> = 1.67; <i>p</i> = 0.09). POS significantly increased the use of ureteral access sheath; OR was 1.49 (95% CI: 1.05–2.13) (<i>Z</i> = 2.22; <i>p</i> = 0.03). Risk of bias assessment showed 13 and 7 studies with low and moderate risk, respectively. <b><i>Conclusions:</i></b> POS clearly improves the stone-free rates after fURS. It might reduce the complications, especially ureteral injury. These findings might help solve the current debate and can be useful for urologists during patient counselling for a proper decision-making.

Is Retrograde Intrarenal Surgery as Safe for Children as It Is for Adults?

<b><i>Introduction:</i></b> The primary aim of this study is to compare the efficacy and safety of retrograde intrarenal surgery (RIRS) among the children and adults with similar stone burdens and locations. Also, the secondary aim of this study is to identify the factors affecting the stone-free rates (SFRs) of RIRS. <b><i>Methods:</i></b> We retrospectively compared perioperative results, SFRs, and complication rates (CRs) between pediatric (group 1, <i>n</i>: 55) and adult (group 2, <i>n</i>: 220) age groups diagnosed with kidney stones and treated by flexible ureterorenoscopy using the same instruments. Furthermore, multivariate analysis was performed to determine the factors affecting the SFR. <b><i>Results:</i></b> A total of 275 patients (pediatric group: 55; adult group: 220) were included in this study. The mean age of pediatric and adult groups was 7.2 ± 5.3 and 43.9 ± 15.1, respectively. The mean stone size was 13.9 ± 6.6 mm in the pediatric group compared to 14.8 ± 6.7 mm in the adult group (<i>p</i> = 0.35). Stone localizations and number were similar. JJ stenting for passive dilatation and use of UAS were higher in the pediatric group (<i>p</i> = 0.002; <i>p</i> = 0.017). However, postoperative double pigtail stenting rate was higher in the adult group (<i>p</i> &#x3c; 0.001). Total CR was 13.8% and mostly Clavien I–II, and no difference was observed between the 2 groups (<i>p</i> = 0.541). The SFRs between the groups were similar (pediatric group: 81.8%; adult group: 78.2%; <i>p</i> = 0.554). On multivariate analysis, stone size (<i>p</i> &#x3c; 0.001) and lower calyx stone (<i>p</i> &#x3c; 0.001) were the negative predictive factors for SFR. <b><i>Conclusion:</i></b> There are small technical differences between pediatric patients and adult patients in our study, but RIRS in children is as safe and efficient as it is in adults.

Mini percutaneous nephrolithotomy versus retrograde flexible ureterorenoscopy in the treatment of renal calculi in anomalous kidneys

Objectives: To report our single center experience in comparing mini-percutaneous nephrolithotomy versus flexible ureterorenoscopy for management of renal stones up to 2 cm in anomalous kidneys. Materials and methods: Records of the last 30 patients with stones less than 2 cm in anomalous kidney treated by mini-percutaneous nephrolithotomy were reviewed and compared to last 30 patients treated by flexible ureterorenoscopy. Results: Mean stone size was significantly higher in the minipercutaneous nephrolithotomy group (17.90 mm) than in flexible ureterorenoscopy group (14.97mm) (p < 0.001). Mean operative time (80.33 min vs 56.43 min) and fluoroscopy exposure time (4.49 min vs 0.84 min) were significantly higher in the mini-percutaneous nephrolithotomy group than in the flexible ureterorenoscopy group (p < 0.001). The mean post-operative drop in hemoglobin concentration was significantly higher in the mini-percutaneous nephrolithotomy group (0.47 gm versus 0.2 gm) (p < 0.001). Stone free rate after 12 weeks follow up was not statistically significant between the 2 groups (90% in minipercutaneous nephrolithotomy vs 80% in flexible ureterorenoscopy) (FEp = 0.472).Conclusions: Both modalities were found to be safe and effective for treatment of stones less than 2 cm in anomalous kidneys.

Predictive factors of stone-free status in renal stone treatment with flexible ureterorenoscopy

Objective: Flexible ureterorenoscopy (fURS) is one of the standard treatments for renal calculi up to 20 mm. This study aims to identify factors associated with stone-free status. Materials and Methods: We included patients undergoing fURS for treatment of small to medium-size renal stone (no single stone larger than 20 mm) from April 2017 to September 2019 at King Chulalongkorn Memorial Hospital. All patients had a preoperative CT scan and postoperative imaging for comparison. We collected patient characteristics (sex, age, previous ipsilateral urinary tract surgery, preoperative ureteral stent placement), stone factors (total stone burden, stone number, stone density) and renal factors (anatomical abnormalities, stone location in a lower pole, number of caliceal involvement) and correlated the data against postoperative stone-free status (defined as residual fragment ≤ 2 mm). Results: The overall stone-free rate was 53.3%. From the univariate analysis, previous surgery, total stone burden, stone number, stone location in the lower pole, and the number of caliceal involvement were associated with stone-free status. However, only the total stone burden remained statistically significant in the multivariate analysis (p-value < 0.05). The stone-free rates were 75.9%, 57.1%, and 11.1% in the total stone burden ≤ 10 mm, 11-20 mm, > 20 mm, respectively. Conclusion: Following treatment of renal stones ≤ 20 mm with fURS, the stone-free rate was 53.3% and was significantly associated with the preoperative total stone burden.