Iris Publishers- Open access Journal of Urology & Nephrology | Role of Retrograde Intrarenal Surgery in Management of Renal Stones: 3 Years Experience

Authored by Yadav Rajinder*

Introduction

The incidence of urinary stone disease is increasing all over the world due to environmental conditions in association with improving health services and diagnostic modalities [1,2]. The management of renal stones has evolved due to technological advancements in last few decades from open to percutaneous to very minimally invasive procedures. The success of these minimally invasive modalities has made open surgery for renal stone disease rare. PCNL (percutaneous nephrolithotomy) became the procedure of choice after its first description in 1976 for management of large burden renal stones and as a treatment option for small renal calculi [3]. Although PCNL had a good stone clearance rate, it is associated with a potential morbidity of bleeding which may need angioembolisation (0.6-1.4%) Michel MS, et al. [4] and so has limitations in patients with bleeding diathesis. Also, PCNL is technically more demanding and is a morbid procedure associated with longer hospitalization, postoperative pain, longer bed rest, and longer time to return to work etc. With rapid advances in technology, miniaturization of endoscopes, improvement in fiberoptic technology, availability of holmium: YAG laser and other ancilliary instruments have rendered RIRS (Retrograde Intrarenal Surgery) a better opportunity for management of renal and ureteric stones. Also, RIRS is associated with low complication rate, minimal morbidity and early return to work
We started flexible ureteroscopy in 2003 with the availability of 30 Watts Holmium laser. Initially we used to do diagnostic ureteroscopy and used to remove small stones left over after fragmentation by ESWL and PCNL and broken stents. With the availability of first flexible ureteroscope we could perform only 30 cases successfully. It was not possible to buy another flexible ureteroscope as it was costly. We borrowed the flexible laryngoscope and performed another 25 cases of removal of small stones from ureter and kidney. Both the scopes were from stortz. With the availability of baskets and flexible ureteroscope we performed RIRS in another 100 cases of upper ureteric and renal stones of up to 2 cm. size. More than 2 cm. size renal stones were treated by PCNL till 2013. With rapid advances in technology, miniaturization of endoscope and video endoscope and improvement in fiber-optic technology, availability of Holmium: YAG laser and other ancillary instruments has rendered RIRS (Retrograde intrarenal surgery) a better opportunity for management of renal and ureteric stones. Also, RIRS is associated with low complication rate, minimal morbidity and early return to work. At present RIRS is limited to patients where PCNL/ESWL are contraindicated because of presence of bleeding diathesis, patients with morbid obesity, malrotated kidney, malpositioned kidney and stone size up to 2 cm [5]. We have evaluated the feasibility and efficacy of RIRS for management of stones including those of stone size > 2cm (including partial and complete staghorn). Staged RIRS is performed for patients with large stone burden (partial and complete staghorn stones) as an alternative to PCNL [6].

Materials and Methods

A prospective study was done from August 2013 to June 2016. 274 patients with renal and upper ureteric stones including stone size > 2 cm to multiple, bilateral including even partial and staghorn stones underwent RIRS at our institution. RIRS was considered the first choice for management of renal stones coming to our hospital irrespective of stone size. Patients were pre-informed about staged procedure if they had bilateral large renal stones. Preoperatively, Stone size and laterality were assessed on NCCT KUB, X-ray KUB films or CT urography. All the patients were investigated for comorbidity. All the patients had urine culture and sensitivity done before the procedure and RIRS was carried out only after urine culture was sterile. Most of the patients were admitted on the same day in the morning and those who were suspected to have infection or obstructed system were pre-stented and treated for a week with appropriate antibiotics to clear the infection and improve renal function in those cases where renal functions were deranged. Almost all patients were operated under general anesthesia except for few cases who were not fit for GA, were done under spinal anesthesia. We did not routinely pre stent the patient. Cystoscopy was performed in all patients to rule out any urethral obstruction or bladder abnormality and to assess the compliance of ureteric orifices. We used video-endoscopes and flexible ureteroscope from Storz and Olympus with double deflection.
All the patients were ureteroscoped by semi-rigid ureteroscope of size 7/8.5 Fr. and guidewire was inserted into the kidney and the ureteroscope was passed up to the renal pelvis. There was no need to dilate ureteric orifice in patients in whom ureteroscope could be passed till renal pelvis and 14/12 Fr. was easily negotiated up to PUJ without any difficulty. We used new ureteroscopic sheath in all patients except in pre-stented patients, where old sheaths were reused. Those patients in whom ureteroscope could not be negotiated, dilatation of orifice was done with balloon dilator. Few of the patients had stricture in ureter, which did not allow urteroscopic dilatation and underwent balloon dilatation. During these procedures, if the patient had pyonephrosis or turbid infected urine, we did not proceed further, and patient was left with the stent and RIRS was done at a second stage. Double guide wire was rarely used. All these procedures were carried out under C-arm guidance.
RGP was not done in most of the cases except in few where the calyces were in awkward position, just to guide the ureteroscope into a particular calyx. Sometimes to access a stone in a difficult calyx, the table was tilted towards right or left depending on the side of the stone or by placing a sandbag under the renal angle. In 9 cases where access sheath could not be negotiated, flexible ureteroscope was guided over flexible biwire into the renal pelvis. We did not reposition the stones from calyces in most cases (except in 4 cases). If calyx was not negotiable, we divided the infundibulum, diverticular or calyceal neck with laser wherever needed, particularly in lower calyx to fragment the stones. We used 200-micron laser fiber in lower calyces and middle calyx stone and 365 microns in upper calyx and pelvic stones. Our energy setting was 0.2 Joules and 10 Hertz. We used painting and popcorn effect in all patients to fragment the stones. We did not used drilling technique. By painting technique, we powdered the stone by keeping the laser fiber 1-2 mm. away from the stone. In most of the cases painting was started from one of the margins and continued on the margins only. At the end of fragmentation, the stone was fragmented by popcorn effect where laser beam was focused in the center of the calyx and fragments flew like popcorns coming in contact with laser and get hit by laser fiber to become tiny fragments. Fragments were not removed except for taking few pieces for chemical analysis.

The stones were observed under C-arm and larger fragments were fragmented if visible. The fragments were basketed by tipless basket or by engage basket for chemical analysis. All the patients were stented after passing a guidewire through the sheath and the sheath was withdrawn under ureteroscopic guidance to see any injury to ureter. The stents were inserted over the guidewire into the collecting system without Ureteroscope and cystoscope by pusher under C-arm guidance. Patient was catheterized for next 24 hours. Most of the patients were discharged after 24 hours and allowed to resume normal work after 2-3 days. All the patients were advised to come for follow-up after 1 week to see the progress. They were advised to get X-ray KUB done after 3 weeks prior to stent removal. If any fragments of stone were found in kidney or ureter, they were relooked and removed during stent removal.

Results

Our case series has the largest study populations in adults published in literature until now. We had in total 274 patients, 185 patients being males and 89 females. 83 patients had single stone, 96patients had multiple stones, 54 patients had partial staghorn stone and 16 patients had staghorn stone. According to stone size 68 patients had < 1cm stone size, 99 patients had stone size 1-2 cm and 107 patients had > 2 cm stone size. 87 patients had unilateral renal stones, 85 patients had bilateral renal stones, 77 patients had renal with ureteric stones and 25 patients had upper ureteric stones (FIgure 1&2).


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