Archives of Urology Category: Clinical Type: Research Article

Comparison of the Outcomes of Retrograde intrarenal Surgery Performed in Upper Urinary Tract Stones of any Size at any Location Using Three Same-Model Flexible Ureterorenoscopes

Yavuz Güler1*
1 Private Safa Hospital, Urology Clinics, Istanbul, Turkey

*Corresponding Author(s):
Yavuz Güler
Private Safa Hospital, Urology Clinics, Istanbul, Turkey
Tel:+90 5058120376,
Email:yavuzguler1976@gmail.com

Received Date: Jan 31, 2020
Accepted Date: Feb 06, 2020
Published Date: Feb 13, 2020
DOI:

Abstract

Aim: To evaluate the patients that were operatively treated using Retrograde ?ntrarenal Surgery (RIRS) with three same-model ureterorenoscopes by a single surgeon in a single clinic between January 1, 2013 and December 31, 2017 and to compare the treatment outcomes. 

Materials and Methods: The retrospective study included a total of 267 patients that underwent RIRS via three different flexible endoscopes of the same brand between January 1, 2013 and December 31, 2017. The 267 patients were divided into three groups based on the endoscope used for each patient: group I (n=85), group II (n=82), and group III (n=100). Demographic characteristics (age, gender, Body Mass ?ndex (BMI), preoperative diseases, and history of Extracorporeal Shockwave Lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL), stone characteristics (affected kidney side, stone size and opacity, and locations of stones in kidneys), and surgical characteristics (operative and fluoroscopy times, use of Ureteral Access Sheath (UAS), characteristics of patients for whom no UAS was implanted, pre- and post operative double-J [JJ] stenting, reasons for JJ stenting, UAS status in prestented patients, and postoperative Visual Analogue Scale (VAS) scores), classification of complications based on the modified Clavien-Dindo Classification System, and the residual rates in subgroups and all patients were reviewed for each patient. All the patients were followed up for 3 months postoperatively. 

Results: The 267 patients were divided into three groups based on the endoscope used for each patient: Group I (n=85), group II (n=82), and group III (n=100). No significant difference was found among the three groups with regard to demographic and stone characteristics and postoperative complications. The number of patients that underwent preoperative ESWL was the lowest in group III. However, significant differences were found among the three groups with regard to surgical characteristics (diameter of Ureteral Access Sheath (UAS), UAS implantation, pre- and post-operative JJ stenting, reasons for preoperative JJ stenting, and UAS implementation in prestented patients). According to the modified Clavien-Dindo Classification, grade I complications were detected in 42, grade II complications in 23, grade IIIa complications in 12, and a grade IV complication was detected in 1 patient. As an auxiliaryprocedure for residual fragments, ESWL was performed in 22, Ureteroscopy and Laser Stonefragmentation (URSL) was performed in 8, and RIRS was performed in 5 patients. The overallresidual rate was 16.5%. The residual rate was 10.5% in stones

Conclusion: Although RIRS may provide successful outcomes in upper urinary tract stones

Keywords

Flexible ureterorenoscopy; Kidney stone; Rirs

INTRODUCTION

Open surgery and Extracorporeal Shockwave Lithotripsy (ESWL) are known as the oldest techniques in the treatment of urinary tract stones. Of these, ESWL has been used since 1980s and remains an important technique in the treatment of urolithiasis [1,2]. Open surgery, on the other hand, has become a less preferred technique since early 1990s, particularly after the emergence of endoscopic instrument technology [3]. Additionally, open surgery is currently almost never used in the treatment of urolithiasis except for specific patients. Technological advancement in the field of ureteroscope technology chiefly involved the introduction of rigid instrumentation and these endoscopes have provided successful outcomes in lower ureteral stones and are currently used as the first-line treatment [4]. On the other hand, rigid ureteroscopes have been tried in the treatment of renal stones and upper ureter stones locatedabove the lower level of the fourth lumbar vertebra corpus, and major complications andtreatment failure have been reported [5]. With the advancement of flexible endoscope technology, however, relatively more successful outcomes with lower complication rates have been reported in upper ureteral and renal stones. Alternatively, Retrograde Intrarenal Surgery (RIRS) has been proposed as a viable technique for patients that are indicated for Percutaneous Nephrolithotomy (PCNL) but also have hemorrhagic diathesis, morbid obesity, and ureteral stones, for patients with musculoskeletal deformities, and also for certain subgroups of patients for whom being stonefree is mandatory such as airline pilots [6]. Nevertheless, although RIRS has been shown to provide successful surgical outcomes in stones of any size, there is no stone size limit defined for RIRS in the literature. 

In the present study, we aimed to evaluate the patients that were operatively treated using RIRS with three different flexible ureterorenoscopes of the same brand by a single surgeon in a single clinic between January 1, 2013 and December 31, 2017 and to compare the treatment outcomes in light of literature.

MATERIALS AND METHODS

Study design 

The retrospective study included a total of 267 patients that underwent RIRS under flexible ureterorenoscopic guidance between January 2013 and December 2017. All the surgical procedures were performed by the same surgeon (Y.G.) at the same clinic, using three different flexible endoscopes of the same brand (Karl-Storz, Tuttlingen/Germany). The 267 patients were divided into three groups based on the endoscope used for each patient: group I (n=85), group II (n=82), and group III (n=100). The study included patients that had no benefit from other stone treatments, had an American Society of Anesthesiologists (ASA) score of <2, and provided a written consent form. However, pediatric patients and patients with abnormal serum creatinine levels were excluded from the study. Demographic characteristics (age, gender, body mass index [BMI], preoperativediseases, and history of ESWL and PCNL), stone characteristics (affected kidney side, stone size and opacity, and locations of stones in kidneys), and surgical characteristics (operative and fluoroscopy times, use of Ureteral Access Sheath (UAS), characteristics of patients for whom no UAS was implanted, pre- and post-operative double-J [JJ] stenting, reasons for JJ stenting, UAS status in patients stented with a JJ stent, and postoperative Visual Analogue Scale (VAS) scores),classification of complications based on the modified Clavien-Dindo Classification System, and the residual rates in subgroups and all patients were reviewed for each patient. 

Preoperative assessment 

Biochemical analysis, urine analysis and culture, plain radiography of the Kidneys, Ureters and Bladder (KUB), renal Ultrasonography (USG), and/or a Computed Tomography (CT) scan were performed for each patient. Stone size was measured as the longest diameter of the stone on the plain radiography of KUB or CT. Patients were taken to surgery after ensuring a negative urine culture. Single-dose Intravenous (IV) ciprofloxacin was used as preoperative prophylaxis. All the surgical procedures were performed under general anesthesia.

Operative technique 

A hydrophilic tip guidewire was inserted to the renal pelvis and then a UAS was placed over the guidewire and advanced into the renal pelvis. In patients in whom the UAS could not be advanced, no balloon dilation was performed. In some of these patients, a flexible ureterorenoscope was placed over the guidewire and advanced to the upper urinary tract; however, in failed cases or occasionally at the discretion of the surgeon, a JJ stent was implanted to achieve passive dilation and the surgery was postponed for 2-4 weeks in these patients. Subsequently, a 8.5 F flexible ureterorenoscope was inserted into the upper urinary tract andstone fragmentation and dusting were performed using a Holmium (Ho): Yttrium-Aluminum Garnet (YAG) laser (200-272 μm fiber) adjusted to produce 0.8-1.5 J at a pulse frequency of 8-15 Hz. For lithotripsy, we generally used the breaking mode for stones below 1 cm, and the dusting mode for stones larger than 1 cm. The fragments were removed with a stone extractor (NGage, Cook Urological Inc., Bloomington, IN, USA) adjusted to 1.7 or 2.2 nm. To facilitate stone fragmentation, the fragments with appropriate sizes were extracted to a suitable calyx or renal pelvis using the NGage basket. After complete fragmentation, a JJ stent or ureteral stent was inserted in eachpatient based on the surgeon’s preference. The operative time was defined as the time from theintroduction of the rigid endoscope to the insertion of a ureteral or JJ stent. Postoperativecomplications were classified according to the modified Clavien-Dindo Classification System (60).

Postoperative follow-up 

At postoperative day 1, biochemical analysis, plain radiography of KUB, renal USG, and non-contrast-enhanced CT were performed for each patient. The same procedures were repeated at postoperative months 1 and 3. Patients with no symptoms or residual fragments smaller than 3 mm were accepted as stone-free. 

Statistical analysis 

Data were analyzed using SPSS for Windows version 22.0 (SPSS Inc. IBM Corp., Armonk, NY, USA). Normality of distribution was assessed using Shapiro-Wilk and Kolmogorov-Smirnov tests. Data with normal distribution were compared using One-Way ANOVA and data with non-normal distribution were compared using Kruskal Wallis test. The post hoc tests were subsequently performed using Tukey’s test. A p value of <0.05 was considered significant.

RESULTS

Table 1 presents the demographic and stone characteristics. Mean age was 45.9±15,1, 43.1±13,9 and 43.6±12,4 years in groups I, II, and III, respectively. The mean stone size of15.45±7.07, 15.73±8.16, and 17.05±8.6 mm in groups I, II, and III, respectively. No significant difference was found between the groups with regard to gender, age, BMI, comorbidity, anticoagulant usage, previous ESWL/ PNL, stone opacity, stone side (right or left), location,and size. Our non-opaque or x-ray negative stone rates were around 30% in all 3 groups. Since not all patients had ncct film, we could not give an average Hu density value in these patients. 

 

Variable

Group-1

(n:85)

Group-2

(n: 82)

Group-3

(n: 100)

 

p

Sex (female/male)

39/46

27/55

29/71

0.14

Age (years), mean ± sd

45.9±15,1

43.1±13,9

43.6±12,4

0.24

BMI (kg/m2), mean ± sd

27.1±5,0

26.4±3,0

26.5±4,4

0.62

Comorbidity, n (%)

Dm

Ht

Cold

 

11 (12.3%)

23 (27.1%)

2 (2.4%)

 

7 (8.5%)

19 (23.2%)

1 (1.2%)

 

9 (9%)

20 (20%)

4 (4%)

0.08

 

Anticoagulant usage, n (%)

5 (5.6%)

3 (3.7%)

7 (7%)

0.07

Previous Eswl/ Pnl, n (%)

Eswl

Pnl

 

46 (54.2%)

2 (2.4%)

 

40 (48.8%)

0

 

33 (33%)

1 (1%)

 

0.04

0.17

Stone opacity, n (%)

Opague

Non-opaque

 

54 (63.5%)

31 (36.5%)

 

57 (69.5%)

25 (30.5%)

 

68 (68%)

32 (32%)

0.69

 

Stone side, n (%)

Right

Left

 

44 (51.8%)

41 (48.2%)

 

42 (51,2%)

40 (48.8%)

 

47 (47%)

53 (53%)

0.92

 

Stone size (mm), mean ± sd

15.4±7.07

15.7±8.16

17.0±8.6

0.25

Stone localization,n (%)

Pelvis

≥2 cm

 

Lower calyx

≥2 cm

 

Ureter

≥2 cm

 

Multiple calyx#

≥2 cm

 

22 (25.9%)

14 (16.5%)

8 (9.4%)

 

25 (29.4%)

14 (16.5%)

11 (12.9%)

 

33 (38.8%)

28 (32.9%)

5 (5.9%)

 

 

5 (5.9%)

 

26 (31.7%)

16 (19.5%)

10 (12.2%)

 

24 (29.3%)

15 (18.3%)

9 (10.1%)

 

24 (29.3%)

21 (25.6%)

3 (3.7%)

 

 

8 (9.8%)

 

31 (31%)

16 (16%)

15 (15%)

 

28 (28%)

19 (19%)

9 (9%)

 

34 (34%)

23 (23%)

11 (11%)

 

 

7 (7%)

 

0.72

 

 

 

0.68

 

 

 

0.11

 

 

 

 

0.23

Table 1: Demographic data and stone characteristics.

sd: Standart Deviation; BMI: Body-Mass Index; Dm:Diabetes Mellitus; Ht:Hypertention; Cold: Chronic obtructive lung disease; Eswl: Extracorporeal Schock Wave Lithotripsy; Pnl: Percutaneous nephtolithotomy

# all stones in this group were larger than 2 cm.

Table 2 presents the operative data. There was a significant differences in terms of pre operative JJ stent, access sheath placement, JJ stent placement between the groups (<0,001, 0,026 and <0,001, respectively). However, operation time and flouroscopy time were not significant. 

Variable

Group-1

(n:85)

Group-2

(n: 82)

Group-3

(n: 100)

 

p

Operation time(min.), mean ± sd

48.4±12.2

 

50.8±16.3

 

48.6±7.1

 

0.53

 

Fluoroscopy time(sec.), mean ± sd

59.6±22.1

 

60.2±26.7

 

57.8±22.5

 

0.42

 

Pre-operative JJ stent, n(%)

43(50.6%)

 

24(29.3%)

19(19%)

<0.001

Access sheath placement, n(%)

 

85 (100%)

64 (78%)

36 (36%)

 0.026

JJ stent placement, n(%)

85 (100%)

72 (87.8%)

74 (74%)

<0.001

 

Post-op VAS score, mean ± sd

4.09±1.6

4.05±1.42

3.9±1.80

0.28

Table 2: Operative data.

VAS: Visual Analog Scale

Table 3 presents the postoperative data. No significant difference was found between the groups with regard to residuel stone, auxiliary treatment and postoperative VAS score.

Variable

Group-1

(n:85)

Group-2

(n: 82)

Group-3

(n: 100)

 

p

Residuel stone, no (%)

overall

 

< 2 cm

≥2 cm

 

pelvis

lower calyx

ureter

multiple calyx

 

17(20%)

 

7(11.3%)

10(34.5%)

 

3/22(13,6)

9/25(36%)

3/33(9,1%)

2/5 (40%)

 

14(17.1%)

 

6(10.7%)

8(26.6%)

 

4/26 (15,4%)

7/24 (29,2%)

3/24 (12,5%)

0/8 (0%)

 

13(13%)

 

4(6.9%)

9(21.4%)

 

3/31 (9,7%)

7/28 (25%)

2/34 (5,6%)

1/7 (14,3%)

 

0.421

 

0.296

0.482

 

0.447

0.3650,550

0.032

 

Auxiliary treatment, no (%)

Eswl

Urs

RIRS

 

7 ( 8,3%)

3 ( 3,5%)

2 ( 2,6%)

 

4 (4,9 %)

1 (1,2 %)

1 (1,2 %)

 

11 (11 %)

4 (4 %)

3 (3 %)

 

0.3740,326

0.577

 

Post-op VAS score, mean ± sd

4.09±1.6

4.05±1.42

3.9±1,80

0.28

 

Table 3: Comparison of the groups in terms of residuel stone, auxiliary treatment and postoperative VAS score .

Eswl: Extracorporeal Schock Wave Lithotripsy; Urs: Ureterorenoscopy; RIRS: Retrograde Intrarenal Surgery; VAS: Visual Analog Scale

Table 4 presents the complication analysis. The overall complications were 29.4%, 32.9% and 27% in groups I, II, and III, respectively. No significant difference was found amongthe groups with regard to complications. 

Variable

Group-1

(n:85)

Group-2

(n: 82)

Group-3

(n: 100)

 

p

Overall complications, no (%)

25 (29.4%)

27 (32.9%)

26 (27.0%)

0.421

Complications, no (%)

fever

uti

urosepsis

perforation

subcapsular hematoma

ileus

steinstrasse

renal colic

JJ-related discomfort

 

3 (3,5 %)

2 (2,4 %)

2 ( 2,4%)

1 ( 1,2%)

1 (1,2 %)

3 ( 3,5%)

2 (2,4 %)

3 ( 3,5%)

8 (9,4 %)

 

1 (1,2 %)

3 (3,7%)

9 (11,0 %)

1 (1,2 %)

0

1 (1,2 %)

3 (3,7 %)

4 (4,9 %)

5 (6,1 %)

 

2 (2 %)

4 (4 %)

3 (3 %)

0 ( %)

0

1 (1 %)

5 ( 5%)

5 ( 5%)

6 ( 6%)

 

0,326

0,392

0,026

0,986

0,325

0,326

0,633

0,678

0,612

 

Modified Clavien-Dindo classification

no complication

grade 1

grade 2

grade 3a

grade 4

 

60 (70,6 %)

17 (12 %)

4 (4,7 %)

3 ( 3,5%)

1 ( 1,2%)

 

55 ( 67,1%)

11 (13,4 %)

12 (14,6 %)

4 (4,9 %)

0

 

74 ( 74%)

14 ( 14 %)

7 ( 7%)

5 ( 5%)

0

 

0,663

0,243

0,031

0,678

0,325

 

Table 4: Comparison of complications between the groups.

DISCUSSION

Extracorporeal Shockwave Lithotripsy (ESWL) is the method of choice in the treatment of renal and ureteral stones <2 cm around the world. ESWL has been reported to provide a stone-free rate of 50-80% and these rates are known to be affected by a number of factors including stone density, BMI, and musculoskeletal deformities. On the other hand, ESWL has been reported to have several drawbacks such as requirement of repeated sessions, long intervals between repeated sessions, and renal colic attacks [7].

Retrograde Intrarenal Surgery (RIRS) is emerging as an increasingly popular technique in the treatment of upper urinary tract stones due to the advancements in flexible endoscopic devices and laser technology. Moreover, RIRS can be used for stones of any size and has been shown to be a viable alternative treatment for patients with failed ESWL or patients who have a stone >2 cm and do not wish to undertake the risk of complications associated with PCNL. 

On the other hand, RIRS can also be successfully used in pediatric and geriatric patients of any age with no need to modify the endoscope. RIRS provides higher stone-free rates compared to ESWL and also leads to shorter hospital stays [8], earlier return to daily life activities, lower complication rates, and acceptable stone-free rates compared to PCNL and mini-PCNL [9]. 

Accumulating evidence suggests that the success of RIRS is associated with a number of factors including the localization of stones in kidneys, stone size, anatomical characteristics of kidneys, period of impaction in ureteral stones, operative time, history of ESWL, preoperative JJ stenting, presence of UAS, and surgical experience [10]. RIRS has been shownto provide a success rate of 90-100% in urinary tract stones

It is commonly known that as the stone size increases, the chance of stone clearance in a single RIRS session decreases. In large stones (≥2 cm), the dust resulting from stone fragmentation, the fragments accumulating in the surgical site, and the mucosal bleeding in theform of hematuria gradually lead to reduced surgical visibility during the surgical procedure. Complete advancement of UAS to the renal pelvis is likely to facilitate renal drainage. In most patients, however, the UAS cannot be advanced to the renal pelvis or migrates to the distal ureter during the surgery and thus total drainage cannot be achieved. 

In our study, although no significant difference was found among the subgroups of patients with a stone ≥2 cm, patients with a stone ≥2 cm had an overall residual rate of 26.7% and a stone-free rate of 73.3%. Some previous studies compared PCNL and RIRS and reported that PCNL is superior to RIRS with regard to stone-free rates and that RIRS may provide acceptable success rates through repeated RIRS sessions. However, the studies also indicatedthat RIRS is superior to PCNL with regard to complication rates, reduced Hb levels,fluoroscopy exposure, and hospitalization periods [12]. Zhao, et al. found that lower calyxstones, multiple calyx stones, and the presence of severe hydronephrosis were significantpredictive factors for lower stone-free rates in RIRS in patients with 2-3 cm stones [13]. On the other hand, a previous study revealed that despite the documented superiority of PCNL over RIRS in stones ≥2 cm with regard to the stone-free rates achieved by a single session and although the patients were informed about this fact, most of the patients preferred RIRS over PCNL. This could be a reason as to why RIRS is an increasingly popular technique for the treatment of stones ≥2 cm. Additionally, a European Association of Urology Section of Urolithiasis (EULIS) Survey compared the effectivity of treatment techniques for renal stones >2 cm and revealed that RIRS is highly popular among urologists [14]. 

Another factor contributing to RIRS success is the calyx harboring the renal stone. The lower calyx is the most difficult to access by endoscopy and is also the most difficult to clear even after stone fragmentation. Literature indicates that the stone-free rates for the lower calyx are lower than those of other calyces even in stones

Factors contributing to RIRS failure in lower calyx stones include Infundibulopelvic Angle (IPA), Infundibular Width (IW), Infundibular Length (IL), Pelvicalyceal Height (PCH), and stone size. Kilicaslan, et al. used a cut-off value of 5 mm for IW in lower calyx stones [18], and Sari, et al. defined the cut-off values for IPA, PCH, and stone size as 69.4, 2.02 cm, and 17 mm, respectively [19]. Based on these findings, we recommend that in patients with lower calyx stones, preoperative urographic findings (intravenous pyelogram (IVP) or CT urography findings) should be evaluated based on these criteria and the patients and their relatives should be informed about the estimated surgical success prior to surgery. 

Literature indicates that RIRS has higher residual rates compared to PCNL particularlyin upper urinary tract stones ≥2 cm. Accordingly, administration of multiple RIRS sessions orthe use of auxiliary procedures is often required to achieve complete stone-free status in stones ≥2 cm [20]. In the present study, ESWL, URSL, and RIRS were performed as auxiliaryprocedures in 22, 8, and 5 patients, respectively. Although these groups differed in terms ofnumber of patients, this difference was statistically insignificant. In total, RIRS, ESWL, and URSL were performed in a total of 272, 22, and 8 patients, respectively, and the overall successrates were calculated based on the non-contrast enhanced CT scans performed at postoperativemonth 1 [21]. 

Flexible Ureterorenoscopy (f-URS) has been shown to provide success rates of up to 100% in small and non-impacted upper ureter stones without causing any complications. However, in impacted, infected, ESWL-refractory upper ureter stones larger than 2 cm, the mucosal edema and polyps caused by long-term pressure of the stone on the mucosa leads to the easily mucosal bleeding and the inadequate working site for lithotripsy, in this case may lead to complications such as inadequate lithotripsy and ureteral perforation and also increase the need for auxiliary procedures, and even may result in nephrectomy due to complete ureteral detachment. 

In our study, the overall residual rate and the stone-free rate for ureteral stones were 8.8% and 91.2%, respectively. Additionally, the overall stone-free rate in patients with stones ≥2 cm, who also included patients that underwent multiple RIRS sessions due to the presence of impacted stones and mucosal polyps, was consistent with the stone-free rates reported for ureteral stones in the literature (72-100%) [22]. 

Double-J (JJ) stenting is often recommended prior to RIRS in patients with sepsis, renal colic, or in whom a UAS cannot be inserted or the endoscope cannot be advanced over the guidewire. In our patients, preoperative JJ stenting was performed in 32.2% of the patients, group I having the highest rate of JJ stenting (50.6%). In all the patients, the most commonreason for JJ stenting was ureteral stenosis (n=47; 54.65%), followed by renal colic (n=22;25.6%) and sepsis (n=17; 19.77%). 

Mahajan, et al. implanted a JJ stent 2 weeks prior to RIRS in 5.4% of the patients in whom the lower ureter could not be dilated [23], Parikh, et al. inserted a JJ stent in 20% of the patients due to Urinary Tract Infections (UTI) and ureteral stricture [24], and Lee, et al. reported that the administration of preoperative ureteral stenting for a period of 7.2 (± 3.7) days reduced the rate of intraoperative ureteral balloon dilation and prevented high-grade ureteral injuries [25]. In contrast, Kawahara, et al. found no significant difference between prestented and nonprestented patients with regard to postoperative stone-free rates although prestenting led to more favorable stone-free rates in stones with a diameter of 2-4 cm [26]. In our study, although JJ stenting facilitated the insertion of UAS, it had no significant effect on the overall postoperative stone-free rate in both stone sizes. 

Implantation of a UAS provides a number of advantages such as reducing intrapelvic pressure, facilitating drainage of intrarenal dust and stone fragments, easy endoscopic access to the kidney, and simple ureteral re-entry. In our study, however, a UAS could not be implanted in 24% of the patients and group III had the lowest rate of UAS usage. In the literature, a number of risk factors have been defined for UAS insertion including advanced age, long-term JJ stenting, and history of Ureterorenoscopy (URS). Some other studies indicated that the rate of UAS usage can be as high as 90% in prestented patients as opposed to 70% in non-prestented patients [27]. Similarly, the rate of UAS usage in our patients was 96.5% in prestentedpatients and was 65.5% in non-prestented patients. These rates implicate that passive dilation may have a significant contribution to UAS insertion. 

In a previous randomized, multicentric study conducted on Intensive Care Unit (ICU) patients, Traxler, et al. evaluated the RIRS outcomes in patients treated with f-URS either with or without UAS support. Although no significant difference was found between the groups with regard to stone-free rates, UAS implantation was found to provide protection against UTI, ureteral lacerations, and bleeding [28]. In our study, the residual rate for stones

Implantation of a JJ stent after RIRS is also a major concern. In our patients, postoperative JJ stenting was performed in 86.5% of the patients, with group I having the highest rate of stenting (100%) and group III having the lowest rate (74%). Astroza, et al. evaluated the effectivity of postoperative JJ stenting on postoperative pain and the requirement for hospital readmission and reported that the stented patients had worse outcomes compared to non-stented patients [29]. Similarly, Bosio, et al. found that ureteral stents were responsible for significant postoperative urinary symptoms and pain [30]. We consider that the use of an overnight 5 or 6f ureteral stent for renal drainage after RIRS could be sufficient in patients with low stone burden and no ureteral trauma or ureteral polyposis. 

In our patients, most of the complications were classified as minor complications except for the two complications in group I (ureteral perforation and subcapsular hematoma) that occurred in one patient each. The ureteral perforation was treated by 4-week JJ stenting and the subcapsular hematoma (55x70x110 mm) was treated conservatively and resolved completely after three months. On the other hand, 14 patients with urosepsis were treated by pathogenspecific antibiotic therapy and had a mean hospital stay of 14 days. Of these, 12 patients were discharged after ensuring a negative urine culture. However, the remaining two patients were discharged with a urine culture positive for Klebsiella pneumoniae. No ICU admission was required in any patient with urosepsis. In our patients, the rate of all postoperative complications was consistent with those reported in the literature for patients undergoing RIRS [6]. 

It is commonly known that the operative time is associated with a number of factors including stone size and localization, use of a basket catheter, surgical experience, and UAS usage. In our patients, mean operative time was 49.24±15.48 min, which was consistent with those reported in the literature for patients undergoing RIRS (25-106 min) [11]. However, nosignificant difference was found among the three groups with regard to operative time.

CONCLUSION

The results implicated that RIRS can be used in the treatment of renal stones of any size. However, it should be noted that in large stones (≥2 cm), acceptable outcomes may not be obtained by a single RIRS session and the patient should be informed about this fact prior to surgery. In conclusion, RIRS is a viable alternative for patients that are suitable for PCNL but have an increased surgical risk or are afraid of PCNL.

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Citation: Güler Y (2020) Comparison of the Outcomes of Retrograde ?ntrarenal Surgery Performed in Upper Urinary Tract Stones of any Size at any Location Using Three Same-Model Flexible Ureterorenoscopes. Arch Urol 3: 008.

Copyright: © 2020  Yavuz Güler, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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