REVIEW URRENT C OPINION

Retrograde intrarenal surgery for kidney stones larger than 2.5 cm Alberto Breda and Oriol Angerri

Purpose of review The management of large intrarenal stones (>2 cm) is typically percutaneous nephrolithotomy. Although the stone-free rate (SFR) of such a procedure is high (up to 95%), the complications related mainly to the renal access are sometimes a concern. Because of the evolution in technology, it is nowadays possible to treat intrarenal stones with retrograde intrarenal surgery. It remains unclear weather or not retrograde intrarenal surgery (RIRS) may be effective also for the treatment of larger stones (>2 cm). The purpose of this review is to provide recent data on the ureteroscopic management of kidney stones larger than 2.5 cm. Recent findings A systematic review of the literature for studies identified between January 2000 and September 2013 was performed. Only English language articles reporting on more than 10 cases treated with RIRS for intrarenal stones larger than 2.5 cm were considered for this review. Particular emphasis was given to studies published within the last 12 months. Of the 324 studies identified, only 10 were considered suitable for this review. There were a total of 441 patients with a mean stone size of 2.9 cm. The SFR with an average of 1.6 procedures was 89.3%. The overall complication rate was 8% with major complication rate of 1.9%. Summary Although not supported by high evidence because of the absence of prospective randomized studies, it appears that in selected patients with large intrarenal stones, RIRS and laser lithotripsy may offer an acceptable efficacy with low morbidity. Keywords 2.5 cm, holmium laser, retrograde intrarenal surgery, stones

INTRODUCTION Both the European Association of Urology (EAU) and American Urological Association (AUA) guidelines recommend extracorporeal shock wave lithotripsy (ESWL) for the management of intrarenal stones smaller than 2 cm and percutaneous nephrolithotomy (PCNL) for the management of large (>2 cm) intrarenal kidney stones because of the high SFR [1,2]. Although there is no doubt that the guidelines provide high level of evidence, it has to be said that the new ‘last minute’ studies may not be reflected by the guidelines themselves. This may well be the case of retrograde intrarenal surgery (RIRS) by mean of flexible ureteroscopy and laser lithotripsy. There is no doubt the RIRS is getting more and more popular because of the advances in technology. Although up until only 3 years ago renal stones smaller than 2 cm were solely recommended to be treated with ESWL [2], the last 2012 edition of the EAU guidelines consider endourology,

by means of PCNL and flexible ureteroscopy, as an alternative for the management of such stones [3]. These recommendations come from retrospective studies and therefore the evidence behind this is low. However, it appears to make a lot of sense that because of the development of smaller and more flexible scopes as well as the digital technology and the improvement of accessories more surgeons are able to approach stones that are less than 2 cm with RIRS with the idea of providing high SFRs with minimal morbidity to the patients. Furthermore, Department of Urology, Fundacio´ Puigvert, Autonoma University of Barcelona, Barcelona, Spain Correspondence to Alberto Breda, MD, Department of Urology, Fundacio` Puigvert, Autonoma University of Barcelona, Calle Cartagena 340-350, 08021 Barcelona, Spain. Tel: +34 934169700; e-mail: [email protected], [email protected] Curr Opin Urol 2014, 24:179–183 DOI:10.1097/MOU.0000000000000030

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Urolithiasis

KEY POINTS  In selected patients, large and complex intrarenal stones can be treated safely and efficiently with flexible ureteroscopy.  Flexible ureteroscopy is an alternative to percutaneous therapy for large stones.  The number of procedures is the main concern for flexible ureteroscopy in large stones.

the fact that PCNL may come with a high morbidity to the patients, has led some authors to investigate the role of RIRS also for the management of larger stones [4–5]. The aim of this review is to provide data on the efficacy and safety of RIRS for the management of renal stones larger than 2.5 cm.

MATERIAL AND METHODS A systematic review of the literature was conducted. Two independent reviewers (A.B. and O.A.) analyzed English language studies published in the MEDLINE literature and Google Scholar within the period form January 2000 to September 2013. Studies related to ureteroscopic management of intrarenal stones larger than 2.5 cm were included.

Only a series larger than 10 patients was considered for this review. Short retrospective series and reviews were excluded. Keywords included: ‘Ureteroscopy’, ‘Flexible’, ‘Large’, ‘Larger 2.5 cm’ ‘stones’, ‘urolithiasis’, ‘holmium laser’, ‘digital’, ‘renal calculi’, ‘lithotripsy’. The following variables were evaluated: country of origin, period of time included for the study, caseload series, stone size, type of lithotripsy, SFR, procedure number per case and complication rate. Because of the limited caseload series, the retrospective aspect for the majority of the studies included and the absence of clinical trials, a metaanalysis was deemed impossible.

RESULTS There were 324 studies identified that reflected the parameters included in the literature search. Of these, 302 were excluded because of nonrelevance based on the titles, series number, study design and abstracts. There were no prospective randomized studies identified. After a careful reading of the studies, 12 were excluded either because of a mean stone size smaller than 2.5 cm or because of different treatment modalities than RIRS. In the end, 10 studies were considered suitable for this review [6,7 ,8,9 ,10–15] (Table 1). These were all cohort observational studies and the majority was published within the last 3 years. Although the &

&

Table 1. Patient demographics Mean age

Sex

Riley et al. [14]

52.1

16 F

Bader et al. [8]

55.8

11 F

Complications (%) 4.5

Crystallography COM 54%

6M 12

COM 54%

13 M Al-Qahtani et al. [7 ]

48

25 F

Hussain et al. [10]

36

NA

NA

Akman et al. [6]

44.5

16 F

11.7

COM 50%

2

COM 53%

6

COM þ apatite 87%

10

COM þ apatite 94%

13

COM þ apatite 45%

5

COM þ apatite 65%

&

8.3

COM 57.7%

23 M NA

18 M Cohen et al. [9 ] &

55

42 F 103 M

Mariani [11]

54.2

4F 9M

Mariani [12]

57.2

9F 7M

Ricchiuti et al. [13]

57.7

11 F 12 M

Takazawa et al. [15]

68

9F 11 M

COM, calcium oxalate monohydrate; F, female; M, male.

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Ureteroscopy for large kidney stones Breda and Angerri Table 2. Patient number and stone-free rates N patients Riley et al. [14]

Stone size (cm)

22

Bader et al. [8]

3

24

Al-Qahtani et al. [7 ] &

Stone free (%)

120

Procedures

91

1.8

3

92

1.7

2.6

96.7

1.6

Hussain et al. [10]

36

2.8

94.4

1.29

Akman et al. [6]

34

2.6

88.2

1.2

Cohen et al. [9 ]

131

3

87

1.6

Mariani [11]

15

3.3

92

1.5

Mariani [12]

16

6.5

88

2.4

Ricchiuti et al. [13]

23

3.1

74

1.4

Takazawa et al. [15]

20

3.1

90

1.4

&

selection criteria to treat stones larger than 2.5 cm was not always clear, the majority of the studies mentioned that the patients were selected either for patient choice, previous ESWL failure, or for high co-morbidities that would exclude PCNL as a possible surgical procedure. There were a total of 441 patients. A mean of the results of the 10 studies was calculated. The mean age was 55 years. There were 143 female and 202 males. One study did not report on their sex. (Table 1) The overall mean stone size was 2.9 cm. Nine studies reported on stones sizes between two and 4 cm, although one study reported on stone size larger than 4 cm. The overall SFR was 89.3%. This was achieved with an average of 1.6 procedures (Table 2). The majority of the studies reported on stone composition. Overall, calcium oxalate monohydrate was the most common stone type (55%) (Table 1). All but two studies [9 ] commonly used ureteral access sheaths for their RIRS. The overall complication rate was 11.5% with a major complication rate of 1.9% (Table 3). No ureteral complications related to the use of access sheaths were reported (Table 1). The overall &

complication rate was 8% with a 1.9% major complication rate.

DISCUSSION Percutaneous nephrolitotomy is considered by both the EAU and AUA guidelines to be the treatment of choice for intrarenal stones larger than 2 cm [1,2,3] because of the high evidence achieved through prospective and randomized studies. Although the SFR of PCNL is reported to be as high as 95% [16,17,18 ] with a single-stage procedure, the complication rate and morbidity related to the procedure has been reported to be as high as 85% with up to 20% of major complications [18 ,19]. On the contrary, there is enough evidence nowadays that ESWL is not indicated for the management of intrarenal stones larger than 2 cm because of the low SFR achieved [3]. As RIRS has been shown to be at least as effective as ESWL for the management of intrarenal stones smaller than 2 cm [20] with a minimal morbidity to the patient [19], there have been increasing interest over the minimally invasive &&

&&

Table 3. Access sheath use and size Acces sheath Riley et al. [14] Bader et al. [8] Al-Qahtani et al. [7 ] &

Size

Prestent Double J

100%

13–15 F

NA

100%

12–14 F

41%

NA

65%

95%

Hussain et al. [10]

Selected cases

NA

NA

Akman et al. [6]

Selected cases

NA

NA

Cohen et al. [9 ]

0%

NA

NA

Mariani [11]

0%

NA

NA

Mariani [12]

0%

NA

NA

Ricchiuti et al. [13]

100%

NA

34,8%

Takazawa et al. [15]

100%

13–15 F o 12–14 F

NA

&

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Urolithiasis

treatment of larger renal stones such as stones larger than 2 cm [4,5,21]. Breda et al. [4] achieved a SFR of 93% with a mean procedure number of 1.4 and a mean stone size of 2.2 cm. A similar experience was reported by Hyams et al. [21] with a 97.5% SFR and a mean stone size of 2.4 cm. Furthermore, RIRS is usually a safer option than PCNL in those patients with a large renal stone and high co-morbidities, spinal and bones malformations and or solitary kidneys because its efficacy has been proven to be high [7 ]. Starting from these good results and thanks to the constant evolution driven by technology, more interest has been posed on the management of larger intrarenal stones such as stones larger than 2.5 cm. Endourologists are nowadays in possession of high quality instruments such as digital ureteroscopes and disposable instruments such as nitinol baskets, small laser fibers, water pumps and ureteral access sheaths. Specifically, the access sheath allows for multiple entrances in the ureter and facilitates stone fragment extraction. Furthermore, it decreases the intrarenal pressure and therefore allows maintaining a good intraureteroscopic flow that results in better vision [5,22]. In this review, although it was difficult to assess whether ureteral access sheaths were utilized, it appears that its use is common in seven out of 10 studies. Only three studies [9 ,11,12] specifically mentioned that they did not use any access sheath for their cases. This review highlighted that the overall SFR was relatively high being 89.3% with an average of 1.6 procedures per patient and a mean stone size of 2.9 cm. It has to be acknowledged that all the studies included in this review are affected by selection biases and therefore these results have to be critically taken. However, it is evident that in selected cases RIRS seems to be a reasonable option to PCNL. Although almost all the studies reported on stone location at the time of treatment, only three studies correlated their SFR with the stone location. Overall the mean SFR was 91, 96.5, 79 and 84% for the upper, mid, lower pole and renal pelvis, respectively [8,9 ,13] (Table 4). As far &

&

&

as complication rate it has been shown how RIRS has been associated with fewer complications than PCNL [6]. Akman et al. [6] compared 34 RIRS to 35 PCNL for stones larger than 2 cm. The SFR was similar between the two groups being 88.2% for RIRS and 91.2% for PCNL, although the RIRS required a mean of 1.2 procedures to achieve these results. The complication rate, hospital stay and overall morbidity were lower in the RIRS than in the PCNL groups. Harmon et al. [23] reported an overall complication rate of RIRS of 1.5% and justified these excellent results with the improvement in technology such as smaller diameter ureteroscopes and better disposable instruments. In this review, the overall complication rate was 8%. Although it was difficult to distinguish between intraoperative and postoperative complications, it appears that the major complication rate was 1.9%. The main major complications reported were urinary sepsis, perirenal hematoma and ureteral perforation. Although not sustained by prospective randomized studies, this review confirms that in selected patients the overall and major complication rate as well as the hospital stay is lower than in PCNL.

LIMITATIONS During the last few years, RIRS has become a more common procedure at many centers around the world. Although there are several studies addressing the efficacy of RIRS for the management of intrarenal stones, there is unfortunately a lack of high evidence data to support its use. This review has highlighted the data in favor of RIRS. In this section, we also highlight the missing data that will need to be addressed in order to compare the different techniques to treat intrarenal stones. The first missing data are related to operative time. Particularly, when treating large intrarenal stones there is no doubt that the time is important. PCNL has been shown to be fast and efficient in the management of large kidney stones [18 ]. Is this also true for &&

Table 4. Stone-free rate according to stone location Upper pole (SFR) Bader et al. [8]

8% (100%)

Cohen et al. [9 ]

10% (85%)

Ricchiuti 13Ricchiuti et al. [13] Takazawa et al. [15]

25% (88%)

&

0%

Medium calix (SFR) 12,5% (100%) 11.5% (93%) NA 5% (100%)

Lower pole (SFR) 8% (100%)

Renal pelvis (SFR)

More than one location

58% (85%)

12.,5% (100%)

27.5% (83%)

24.4% (94%)

NA

37% (83%)

37% (58%)

NA

40% (50%)

35% (100%)

15% (0%)

SFR, stone-free rate.

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Ureteroscopy for large kidney stones Breda and Angerri

RIRS? It is unfortunate that there is no clear evidence from the literature and from this review on the time limitations of RIRS for the management of larger than 2.5 cm renal stones. The second missing point is related to stone location. Although the majority of the studies describe the location of the stone at treatment, there is a lack of data on the SFR related to the stone location. The third missing value is related to SFR diagnosis. There is no agreement on how to define it. No residual fragments at all, fragments smaller than 2 mm, smaller than 3 mm and smaller than 4 mm? Furthermore, the diagnostic imaging technique is not standardized at all, with the majority of the studies mixing between computed tomography scans, ultrasonography, kidney ureter bladder, intravenous urography or a combination of these. It is also not clear whether the use of access sheaths is indicated at all. There is a lack of data on the size of the access sheath to be used, on the need to present a patient, and on the intra and postoperative complications related to its use. Finally, as previously stated, there is no randomized controlled trial comparing RIRS and PCNL for the management of large renal stones rendering every attempt to compare the two procedures very improbable.

CONCLUSION Although not supported by high evidence because of the absence of prospective randomized studies, it appears that in selected patients with large intrarenal stones (>2.5 cm), retrograde intrarenal surgery by means of flexible ureteroscopy and laser lithotripsy may offer an acceptable efficacy with low morbidity for the patient. The patients have to be informed that these results are not coming form prospective randomized data and therefore the decision-making has to be accurately discussed. Furthermore, it has to be stressed that the high SFR is achieved with a higher average procedure number than PCNL. Acknowledgements None. Conflicts of interest There are no conflicts of interest.

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Retrograde intrarenal surgery for kidney stones larger than 2.5 cm.

The management of large intrarenal stones (>2 cm) is typically percutaneous nephrolithotomy. Although the stone-free rate (SFR) of such a procedure is...
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