Endourology and Stones Flexible Ureterorenoscopy Is Safe and Efficient for the Treatment of Kidney Stones in Patients With Chronic Kidney Disease Emrah Yuruk, Murat Binbay, Faruk Ozgor, Akif Erbin, Yalcin Berberoglu, and Ahmet Y. Muslumanoglu OBJECTIVE PATIENTS AND METHODS
RESULTS
CONCLUSION
To evaluate the outcomes of kidney stone treatment using flexible ureterorenoscopy (f-URS) among patients with chronic kidney disease (CKD). Data of patients who underwent f-URS between January 2009 and December 2012 were collected. Patients were staged according to estimated glomerular filtration rate. Patients with stage 3 were accepted as having CKD (study group). These patients were matched with a group of patients without CKD (control group). Operative characteristics, complication rates, and third-month success rates were compared. Overall, 339 patients underwent f-URS and 62 (18.28%) had CKD. Control group constituted of 87 patients. Having a solitary kidney (17.4% vs 3.5%; P ¼ .003) and history of stone intervention (51.6% vs 23%; P ¼ .001) were more common in the CKD group. Similarly, access sheath was more commonly used among patients with CKD (87.1% vs 70.22%; P ¼ .015). Both perioperative (19.35% vs 19.54; P ¼ .372) and postoperative (22.6% vs 16.1%; P ¼ .214) complication rates were similar in patients with and without CKD. Hospitalization time was 25.70 25.62 and 24.5 25 hours (P ¼ .871) for patients with and without CKD, respectively. Although mean third postoperative estimated glomerular filtration rate of patients with CKD did not change significantly (48.16 8.72 vs 49.08 9.26; P ¼ .431), CKD stage of 13 patients shifted from 3 to 2. At the third postoperative month, stone free rate in patients with and without CKD was 87.1% vs 86.2% (P ¼ .875). f-URS is a safe and effective procedure in patients with CKD and it is associated with improved overall kidney function. UROLOGY 84: 1279e1284, 2014. 2014 Elsevier Inc.
S
ymptomatic kidney stone is one of the most common problems encountered in urology practice, and urinary tract obstruction secondary to stone disease may result in renal injury.1 Increased risk of chronic kidney disease (CKD) among stone formers has been shown by population-based studies, and reported prevalence of CKD with urolithiasis varies from 1.7% to 18%.1-3 CKD is also a common and serious public health problem affecting 10%-16% of the adult population and is associated with high morbidity and mortality rates.4-6 CKD is associated with in anemia, leukopenia, thrombocytopenia, and impairment in platelet function.7
Financial Disclosure: The authors declare that they have no relevant financial interests. The Department of Urology, Bagcilar Training and Research Hospital, Istanbul, Turkey; and the Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey Address correspondence to: Emrah Yuruk, M.D., Department of Urology, Bagcilar Training and Research Hospital, Merkez M. 6. Sok, Istanbul 34200, Turkey. E-mail: [email protected] Submitted: April 29, 2014, accepted (with revisions): July 22, 2014
ª 2014 Elsevier Inc. All Rights Reserved
As a result, patients with CKD have a tendency for infection, sepsis, and bleeding during or after any forms of intervention including stone removal.7 Electrolyte imbalance, fluid overload, and the resultant pulmonary edema may also develop as a result of impaired renal function.7 Finally, during the course of the disease, cardiac dysfunction including cardiomyopathy may result.7 All these comorbid conditions associated with ongoing kidney disease may increase the risk of any kind of anesthesia and intervention and impair the outcome of surgery.7,8 Several studies demonstrated the short- and long-term safety of flexible ureterorenoscopy (f-URS) in patients with normal kidney function.9,10 However, to our knowledge, there are not any studies evaluating the efficacy and safety of this procedure among kidney stone patients with CKD. Therefore, we performed this retrospective analysis to compare operative characteristics, complications, and the outcomes of f-URS between patients with CKD and without CKD and demonstrate the effect of stone removal on kidney function in patients with CKD. http://dx.doi.org/10.1016/j.urology.2014.07.038 0090-4295/14
1279
PATIENTS AND METHODS Study Design Data of patients who underwent f-URS for the treatment of kidney stones at our tertiary referral center from January 2009 until December 2012 were analyzed retrospectively. Estimated glomerular filtration rate (eGFR) was calculated using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula for each patient.11 The calculations were made using the application on Web page of National Kidney Foundation (NKF), and patients were staged according to their eGFR as follows11,12: Stage 1: normal (eGFR >90 mL/min/1.73 mm2) Stage 2: mildly decreased (60-89 mL/min/1.73 mm2) Stage 3: moderately decreased (30-59 mL/min/1.73 mm2) Stage 4: severely decreased (15-29 mL/min/1.73 mm2) Stage 5: requiring renal replacement therapy including dialysis and renal transplant (2 cm. Accessible calices were determined under fluoroscopic guidance. A 7.5F fiberoptic (FLEX-X2; Karl Storz, Tuttlingen, Germany) or 8.7F digital flexible ureteroscope (DUR-D Gyrus; ACMI, Southborough, MA) were used with a 200 or 273 mm laser fiber. The holmium laser machine (StoneLight; AMS, Minnetonka, MN) was set at 1.0-1.5 J and 8-10 Hz depending on the type of stone fragmentation technique preferred. At the end of laser lithotripsy, stone fragments
RESULTS
CONCLUSION
To evaluate the outcomes of kidney stone treatment using flexible ureterorenoscopy (f-URS) among patients with chronic kidney disease (CKD). Data of patients who underwent f-URS between January 2009 and December 2012 were collected. Patients were staged according to estimated glomerular filtration rate. Patients with stage 3 were accepted as having CKD (study group). These patients were matched with a group of patients without CKD (control group). Operative characteristics, complication rates, and third-month success rates were compared. Overall, 339 patients underwent f-URS and 62 (18.28%) had CKD. Control group constituted of 87 patients. Having a solitary kidney (17.4% vs 3.5%; P ¼ .003) and history of stone intervention (51.6% vs 23%; P ¼ .001) were more common in the CKD group. Similarly, access sheath was more commonly used among patients with CKD (87.1% vs 70.22%; P ¼ .015). Both perioperative (19.35% vs 19.54; P ¼ .372) and postoperative (22.6% vs 16.1%; P ¼ .214) complication rates were similar in patients with and without CKD. Hospitalization time was 25.70 25.62 and 24.5 25 hours (P ¼ .871) for patients with and without CKD, respectively. Although mean third postoperative estimated glomerular filtration rate of patients with CKD did not change significantly (48.16 8.72 vs 49.08 9.26; P ¼ .431), CKD stage of 13 patients shifted from 3 to 2. At the third postoperative month, stone free rate in patients with and without CKD was 87.1% vs 86.2% (P ¼ .875). f-URS is a safe and effective procedure in patients with CKD and it is associated with improved overall kidney function. UROLOGY 84: 1279e1284, 2014. 2014 Elsevier Inc.
S
ymptomatic kidney stone is one of the most common problems encountered in urology practice, and urinary tract obstruction secondary to stone disease may result in renal injury.1 Increased risk of chronic kidney disease (CKD) among stone formers has been shown by population-based studies, and reported prevalence of CKD with urolithiasis varies from 1.7% to 18%.1-3 CKD is also a common and serious public health problem affecting 10%-16% of the adult population and is associated with high morbidity and mortality rates.4-6 CKD is associated with in anemia, leukopenia, thrombocytopenia, and impairment in platelet function.7
Financial Disclosure: The authors declare that they have no relevant financial interests. The Department of Urology, Bagcilar Training and Research Hospital, Istanbul, Turkey; and the Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey Address correspondence to: Emrah Yuruk, M.D., Department of Urology, Bagcilar Training and Research Hospital, Merkez M. 6. Sok, Istanbul 34200, Turkey. E-mail: [email protected] Submitted: April 29, 2014, accepted (with revisions): July 22, 2014
ª 2014 Elsevier Inc. All Rights Reserved
As a result, patients with CKD have a tendency for infection, sepsis, and bleeding during or after any forms of intervention including stone removal.7 Electrolyte imbalance, fluid overload, and the resultant pulmonary edema may also develop as a result of impaired renal function.7 Finally, during the course of the disease, cardiac dysfunction including cardiomyopathy may result.7 All these comorbid conditions associated with ongoing kidney disease may increase the risk of any kind of anesthesia and intervention and impair the outcome of surgery.7,8 Several studies demonstrated the short- and long-term safety of flexible ureterorenoscopy (f-URS) in patients with normal kidney function.9,10 However, to our knowledge, there are not any studies evaluating the efficacy and safety of this procedure among kidney stone patients with CKD. Therefore, we performed this retrospective analysis to compare operative characteristics, complications, and the outcomes of f-URS between patients with CKD and without CKD and demonstrate the effect of stone removal on kidney function in patients with CKD. http://dx.doi.org/10.1016/j.urology.2014.07.038 0090-4295/14
1279
PATIENTS AND METHODS Study Design Data of patients who underwent f-URS for the treatment of kidney stones at our tertiary referral center from January 2009 until December 2012 were analyzed retrospectively. Estimated glomerular filtration rate (eGFR) was calculated using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula for each patient.11 The calculations were made using the application on Web page of National Kidney Foundation (NKF), and patients were staged according to their eGFR as follows11,12: Stage 1: normal (eGFR >90 mL/min/1.73 mm2) Stage 2: mildly decreased (60-89 mL/min/1.73 mm2) Stage 3: moderately decreased (30-59 mL/min/1.73 mm2) Stage 4: severely decreased (15-29 mL/min/1.73 mm2) Stage 5: requiring renal replacement therapy including dialysis and renal transplant (2 cm. Accessible calices were determined under fluoroscopic guidance. A 7.5F fiberoptic (FLEX-X2; Karl Storz, Tuttlingen, Germany) or 8.7F digital flexible ureteroscope (DUR-D Gyrus; ACMI, Southborough, MA) were used with a 200 or 273 mm laser fiber. The holmium laser machine (StoneLight; AMS, Minnetonka, MN) was set at 1.0-1.5 J and 8-10 Hz depending on the type of stone fragmentation technique preferred. At the end of laser lithotripsy, stone fragments
