World J Urol DOI 10.1007/s00345-014-1305-6
Original Article
Is retrograde intrarenal surgery a viable treatment option for renal stones in patients with solitary kidney? G. Giusti · S. Proietti · L. Cindolo · R. Peschechera · G. Sortino · F. Berardinelli · G. Taverna
Received: 21 February 2014 / Accepted: 10 April 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To evaluate the effectiveness and safety of retrograde intrarenal surgery (RIRS) for stones up to 2 cm in diameter in patients with solitary kidney. Methods From January 2008 to January 2013, we prospectively enrolled all consecutive patients with solitary kidney and renal stones. Plain abdominal computed tomography scan was performed preoperatively and 1 month after the procedure to assess the stone-free rates (SFR). Serum creatinine levels were detected preoperatively, at day 1 postoperatively, at 1 month postoperatively, and then every 6 months postoperatively. Results During the study period, we prospectively enrolled a total of 29 patients. The mean age was 55.7 ± 12.3 years; the mean stone size was 1.3 ± 0.4 cm. The primary SFR was 72.4 %; the secondary SFR was 93.1 %. The mean number of procedures per patient was 1.24. The mean serum creatinine levels were 1.5 ± 0.6, 1.6 ± 0.7, 1.6 ± 0.6, and 1.7 ± 0.7 mg/dl preoperatively, at 1 day after RIRS, at 1 month after RIRS, and at 1 year after RIRS, respectively, without detection of any statistical difference (p = 0.76). Median follow-up time was 35.7 ± 19.3 (12–72) months, but that was available for only 18 patients. The mean serum creatinine level at the last follow-up was G. Giusti · S. Proietti (*) · R. Peschechera · G. Sortino · G. Taverna Stone Center at Department of Urology, Humanitas Clinical and Research Center, Rozzano, Italy e-mail: [email protected] L. Cindolo · F. Berardinelli Department of Urology, “S.Pio da Pietrelcina” Hospital, Vasto, Italy G. Sortino Department of Urology, “G. Rodolico” Hospital, Catania, Italy
1.7 ± 0.9 mg/dl. No major complications were recorded. Grade I complications occurred in eight patients (27.4 %). Conclusions RIRS is safe and effective in the treatment of renal stones in patients with solitary kidney, without worsening renal function. Keywords Solitary kidney · Stone · Retrograde intrarenal surgery · Renal function
Introduction Patients with solitary kidney and renal stones are traditionally treated with percutaneous nephrolithotomy (PCNL) or extracorporeal shock wave lithotripsy (SWL), depending on the stone size and body habitus. In patients with bilateral kidneys, retrograde intrarenal surgery (RIRS) has been shown as a viable, effective and safe alternative to both PCNL and SWL, with high stonefree rates (SFR) and low complication rate. To date, only one retrospective study has analyzed the outcomes of RIRS in the treatment of renal stones in patients with solitary kidney; it has shown high success rates, stable renal function, and low minor complication rates [1]. In this prospective study, we report our series of patients with solitary kidney who underwent RIRS for renal stones.
Materials and methods From January 2008 to February 2013, we prospectively enrolled all consecutive patients with solitary kidney affected with renal stones and who underwent RIRS. Inclusion criteria were age older than 18 years, solitary kidney, and renal stones up to 2 cm in diameter. Exclusion
13
criteria were pregnancy, urinary tract abnormalities, and positive urine culture. The study was approved by the local ethics committee and patients provided informed consent. Preoperative and 1-month work-up included history, physical examination, urinalysis, urine culture, hematocrit level, and plain abdominal computed tomography (CT) scan. After the second procedure, urinary ultrasonography (instead of CT scan) was performed to evaluate SFR to reduce the radiation exposure to the patient. Serum creatinine levels were evaluated preoperatively and at 1 day postoperatively, at 1-month follow-up, and then every 6 months. The Clavien classification of complications modified by Dindo was used [2]. The stone size was calculated by measuring the maximum stone diameter on CT scan. SFR was defined as clinically insignificant residual fragments 2 mm or smaller detected on CT scan. In case of significant residual stone, the patient was immediately scheduled for a second-look procedure within 2 weeks. In case of an uneventful procedure, JJ stent was removed after 10 days. The primary endpoint was to evaluate the SFR after RIRS in patients with solitary kidney and renal calculi. The secondary endpoint was to calculate renal function variation related to the procedure during follow-up. Statistical analysis was performed with SPSS version 17 for Windows (IBM, Armonk, NY, USA). Comparisons among preoperative and postoperative serum creatinine levels during the study period were performed using the Kruskal–Wallis test with the Dunn multiple comparison test. Data are expressed as median (interquartile range) or median ± standard deviation. Statistical significance was considered at p 0.05). All stones could be reached ureteroscopically; no inaccessible ureters were encountered. During the primary procedures, a 12–14-F UAS was placed in 22 patients (75.8 %) and a 9.5–11.5-F UAS or a 10–12-F UAS was placed in five patients (17.2 %); in the remaining two patients (6.8 %), the ureter was not compliant and the procedure was performed sheathless. During the second procedure, all ureters were negotiable with a 12-14-F UAS. Abdominal CT scan demonstrated SFR of 79.3 %. One month after the second procedure, abdominal ultrasound showed SFR of 93.1 %. Two patients with residual stones, smaller than 0.5 cm in diameter and located in the lower calyx, were asymptomatic and free of upper urinary tract obstruction.
Discussion In patients with solitary kidney and concomitant urolithiasis, it is mandatory to completely remove the stones to avoid any potential obstruction that could damage renal function. Patients with solitary kidney and renal stones are traditionally treated with PCNL or SWL. Despite this, in the past few years, thanks to advancements in the
endourological disposable armamentarium and along with the downsizing of flexible ureteroscopes and the advent of digital technology and holmium laser lithotripsy, RIRS has increasingly gained popularity among the urological community, even for special circumstances. SWL, even though it is noninvasive, is characterized by complications that can affect renal function and that can be risky in patients with solitary kidney because of the absence of the functional compensation of the contralateral kidney. In fact, complication frequencies have been demonstrated as follows: residual stone fragments with formation of steinstrasse, 4–7 % of cases; regrowth of residual fragments, 21–59 %; urinary tract infections and sepsis, 1–2.7 %; symptomatic renal hematoma,
Original Article
Is retrograde intrarenal surgery a viable treatment option for renal stones in patients with solitary kidney? G. Giusti · S. Proietti · L. Cindolo · R. Peschechera · G. Sortino · F. Berardinelli · G. Taverna
Received: 21 February 2014 / Accepted: 10 April 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To evaluate the effectiveness and safety of retrograde intrarenal surgery (RIRS) for stones up to 2 cm in diameter in patients with solitary kidney. Methods From January 2008 to January 2013, we prospectively enrolled all consecutive patients with solitary kidney and renal stones. Plain abdominal computed tomography scan was performed preoperatively and 1 month after the procedure to assess the stone-free rates (SFR). Serum creatinine levels were detected preoperatively, at day 1 postoperatively, at 1 month postoperatively, and then every 6 months postoperatively. Results During the study period, we prospectively enrolled a total of 29 patients. The mean age was 55.7 ± 12.3 years; the mean stone size was 1.3 ± 0.4 cm. The primary SFR was 72.4 %; the secondary SFR was 93.1 %. The mean number of procedures per patient was 1.24. The mean serum creatinine levels were 1.5 ± 0.6, 1.6 ± 0.7, 1.6 ± 0.6, and 1.7 ± 0.7 mg/dl preoperatively, at 1 day after RIRS, at 1 month after RIRS, and at 1 year after RIRS, respectively, without detection of any statistical difference (p = 0.76). Median follow-up time was 35.7 ± 19.3 (12–72) months, but that was available for only 18 patients. The mean serum creatinine level at the last follow-up was G. Giusti · S. Proietti (*) · R. Peschechera · G. Sortino · G. Taverna Stone Center at Department of Urology, Humanitas Clinical and Research Center, Rozzano, Italy e-mail: [email protected] L. Cindolo · F. Berardinelli Department of Urology, “S.Pio da Pietrelcina” Hospital, Vasto, Italy G. Sortino Department of Urology, “G. Rodolico” Hospital, Catania, Italy
1.7 ± 0.9 mg/dl. No major complications were recorded. Grade I complications occurred in eight patients (27.4 %). Conclusions RIRS is safe and effective in the treatment of renal stones in patients with solitary kidney, without worsening renal function. Keywords Solitary kidney · Stone · Retrograde intrarenal surgery · Renal function
Introduction Patients with solitary kidney and renal stones are traditionally treated with percutaneous nephrolithotomy (PCNL) or extracorporeal shock wave lithotripsy (SWL), depending on the stone size and body habitus. In patients with bilateral kidneys, retrograde intrarenal surgery (RIRS) has been shown as a viable, effective and safe alternative to both PCNL and SWL, with high stonefree rates (SFR) and low complication rate. To date, only one retrospective study has analyzed the outcomes of RIRS in the treatment of renal stones in patients with solitary kidney; it has shown high success rates, stable renal function, and low minor complication rates [1]. In this prospective study, we report our series of patients with solitary kidney who underwent RIRS for renal stones.
Materials and methods From January 2008 to February 2013, we prospectively enrolled all consecutive patients with solitary kidney affected with renal stones and who underwent RIRS. Inclusion criteria were age older than 18 years, solitary kidney, and renal stones up to 2 cm in diameter. Exclusion
13
criteria were pregnancy, urinary tract abnormalities, and positive urine culture. The study was approved by the local ethics committee and patients provided informed consent. Preoperative and 1-month work-up included history, physical examination, urinalysis, urine culture, hematocrit level, and plain abdominal computed tomography (CT) scan. After the second procedure, urinary ultrasonography (instead of CT scan) was performed to evaluate SFR to reduce the radiation exposure to the patient. Serum creatinine levels were evaluated preoperatively and at 1 day postoperatively, at 1-month follow-up, and then every 6 months. The Clavien classification of complications modified by Dindo was used [2]. The stone size was calculated by measuring the maximum stone diameter on CT scan. SFR was defined as clinically insignificant residual fragments 2 mm or smaller detected on CT scan. In case of significant residual stone, the patient was immediately scheduled for a second-look procedure within 2 weeks. In case of an uneventful procedure, JJ stent was removed after 10 days. The primary endpoint was to evaluate the SFR after RIRS in patients with solitary kidney and renal calculi. The secondary endpoint was to calculate renal function variation related to the procedure during follow-up. Statistical analysis was performed with SPSS version 17 for Windows (IBM, Armonk, NY, USA). Comparisons among preoperative and postoperative serum creatinine levels during the study period were performed using the Kruskal–Wallis test with the Dunn multiple comparison test. Data are expressed as median (interquartile range) or median ± standard deviation. Statistical significance was considered at p 0.05). All stones could be reached ureteroscopically; no inaccessible ureters were encountered. During the primary procedures, a 12–14-F UAS was placed in 22 patients (75.8 %) and a 9.5–11.5-F UAS or a 10–12-F UAS was placed in five patients (17.2 %); in the remaining two patients (6.8 %), the ureter was not compliant and the procedure was performed sheathless. During the second procedure, all ureters were negotiable with a 12-14-F UAS. Abdominal CT scan demonstrated SFR of 79.3 %. One month after the second procedure, abdominal ultrasound showed SFR of 93.1 %. Two patients with residual stones, smaller than 0.5 cm in diameter and located in the lower calyx, were asymptomatic and free of upper urinary tract obstruction.
Discussion In patients with solitary kidney and concomitant urolithiasis, it is mandatory to completely remove the stones to avoid any potential obstruction that could damage renal function. Patients with solitary kidney and renal stones are traditionally treated with PCNL or SWL. Despite this, in the past few years, thanks to advancements in the
endourological disposable armamentarium and along with the downsizing of flexible ureteroscopes and the advent of digital technology and holmium laser lithotripsy, RIRS has increasingly gained popularity among the urological community, even for special circumstances. SWL, even though it is noninvasive, is characterized by complications that can affect renal function and that can be risky in patients with solitary kidney because of the absence of the functional compensation of the contralateral kidney. In fact, complication frequencies have been demonstrated as follows: residual stone fragments with formation of steinstrasse, 4–7 % of cases; regrowth of residual fragments, 21–59 %; urinary tract infections and sepsis, 1–2.7 %; symptomatic renal hematoma,
