Abstract
Purpose
The international guidelines on urolithiasis state that the percutaneous approach is superior for kidney stones ≥20 mm. Nevertheless, several groups have reported high stone-free rates (SFRs) with low morbidity for ureteroscopic treatment of calculi >15 mm. We hereby describe a new technique including the combined use of semirigid and flexible ureteroscopy via a large ureteral access sheath (UAS).
Methods
The proposed technique includes (a) preoperative ureteral stenting, (b) use of a large lumen UAS (14/16F, 35 cm), (c) use of a semirigid ureteroscope, (d) holmium laser lithotripsy, (e) passive and (f) active fragment extraction, and finally, the removal of caliceal stones (g) using a flexible scope. We conducted a prospective outcome analysis for 38 patients treated at two tertiary university centers.
Results
Perioperative data were as follows: median cumulative stone size 24.5 mm (20–60), median operating time 95 min (50–205), post-operative ureteral stenting (2–35 days) in 33 patients (86.8 %), Clavien complications 2 and 3 in 7.9 %, primary SFR 63.2 %, and overall computed tomography (CT) controlled SFR after 3 months 81.8 % (including staged procedures). No late complications were observed.
Conclusions
The combined use of semirigid ureteroscopy and an UAS further develops the endoscopic treatment of kidney stones. This is the first series of this kind that confirms high SFRs by CT. The approach has significant advantages: Superior irrigation and outflow enhance both vision and stone clearance, and multiple ureteral passages without putting the ureter at injury risk. These encouraging results make this modality an appealing alternative to percutaneous nephrolithotomy.
Similar content being viewed by others
Abbreviations
- CT:
-
Computed tomography
- DJ:
-
Double-J catheter
- PCNL:
-
Percutaneous nephrolithotomy
- SFR:
-
Stone-free rate
- UAS:
-
Ureteral access sheath
References
Aboumarzouk OM, Monga M, Kata SG, Traxer O, Somani BK (2012) Flexible ureteroscopy and laser lithotripsy for stones >2 cm: a systematic review and meta-analysis. J Endourol 26(10):1257–1263. doi:10.1089/end.2012.0217
Tuerk C, Knoll T, Petrik A et al (2013) Guidelines on urolithiasis. http://www.uroweb.org/gls/pdf/21_Urolithiasis_LR.pdf
Bryniarski P, Paradysz A, Zyczkowski M, Kupilas A, Nowakowski K, Bogacki R (2012) A randomized controlled study to analyze the safety and efficacy of percutaneous nephrolithotripsy and retrograde intrarenal surgery in the management of renal stones more than 2 cm in diameter. J Endourol 26(1):52–57. doi:10.1089/end.2011.0235
Atis G, Gurbuz C, Arikan O, Canat L, Kilic M, Caskurlu T (2012) Ureteroscopic management with laser lithotripsy of renal pelvic stones. J Endourol 26(8):983–987
Kourambas J, Byrne RR, Preminger GM (2001) Does a ureteral access sheath facilitate ureteroscopy? J Urol 165(3):789–793
Schoenthaler M, Wilhelm K, Kuehhas FE, Farin E, Bach C, Buchholz N, Miernik A (2012) Postureteroscopic lesion scale: a new management modified organ injury scale-evaluation in 435 ureteroscopic patients. J Endourol 26(11):1425–1430
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6,336 patients and results of a survey. Ann Surg 240(2):205–213
Matlaga BR, Jansen JP, Meckley LM, Byrne TW, Lingeman JE (2012) Treatment of ureteral and renal stones: a systematic review and meta-analysis of randomized, controlled trials. J Urol 188(1):130–137. doi:10.1016/j.juro.2012.02.2569
de la Rosette J, Assimos D, Desai M, Gutierrez J, Lingeman J, Scarpa R, Tefekli A (2011) The clinical research office of the endourological society percutaneous nephrolithotomy global study: indications, complications, and outcomes in 5,803 patients. J Endourol 25(1):11–17. doi:10.1089/end.2010.0424
Aso Y, Ohta N, Nakano M, Ohtawara Y, Tajima A, Kawabe K (1990) Treatment of staghorn calculi by fiberoptic transurethral nephrolithotripsy. J Urol 144(1):17–19
Grasso M, Conlin M, Bagley D (1998) Retrograde ureteropyeloscopic treatment of 2 cm. or greater upper urinary tract and minor Staghorn calculi. J Urol 160(2):346–351
Skolarikos A, Papatsoris AG (2009) Diagnosis and management of postpercutaneous nephrolithotomy residual stone fragments. J Endourol 23(10):1751–1755
El-Nahas AR, El-Assmy AM, Mansour O, Sheir KZ (2007) A prospective multivariate analysis of factors predicting stone disintegration by extracorporeal shock wave lithotripsy: the value of high-resolution noncontrast computed tomography. Eur Urol 51(6):1688–1693
Park J, Hong B, Park T, Park HK (2007) Effectiveness of noncontrast computed tomography in evaluation of residual stones after percutaneous nephrolithotomy. J Endourol 21(7):684–687
Osman Y, El-Tabey N, Refai H, Elnahas A, Shoma A, Eraky I, Kenawy M, El-Kapany H (2008) Detection of residual stones after percutaneous nephrolithotomy: role of nonenhanced spiral computerized tomography. J Urol 179(1):198–200
Kluner C, Hein PA, Gralla O, Hein E, Hamm B, Romano V, Rogalla P (2006) Does ultra-low-dose CT with a radiation dose equivalent to that of KUB suffice to detect renal and ureteral calculi? J Comput Assist Tomogr 30(1):44–50
Miernik A, Wilhelm K, Ardelt PU, Adams F, Kuehhas FE, Schoenthaler M (2012) Standardized flexible ureteroscopic technique to improve stone-free rates. Urology 80(6):1198–1202
Bach C, Nesar S, Kumar P, Goyal A, Kachrilas S, Papatsoris A, Masood J, Buchholz N (2012) The new digital flexible ureteroscopes: ‘size does matter’—increased ureteric access sheath use! Urol Int 89(4):408–411
Khan SR (1997) Animal models of kidney stone formation: an analysis. World J Urol 15(4):236–243
Hyams ES, Shah O (2009) Percutaneous nephrostolithotomy versus flexible ureteroscopy/holmium laser lithotripsy: cost and outcome analysis. J Urol 182(3):1012–1017
Kawahara T, Ito H, Terao H, Ishigaki H, Ogawa T, Uemura H, Kubota Y, Matsuzaki J (2012) Preoperative stenting for ureteroscopic lithotripsy for a large renal stone. Int J Urol 19(9):881–885. doi:10.1111/j.1442-2042.2012.03046.x
Traxer O, Thomas A (2013) Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 189(2):580–584
Netsch C, Knipper S, Bach T, Herrmann TR, Gross AJ (2012) Impact of preoperative ureteral stenting on stone-free rates of ureteroscopy for nephroureterolithiasis: a matched-paired analysis of 286 patients. Urology 80(6):1214–1219
Cohen J, Cohen S, Grasso M (2012) Ureteropyeloscopic treatment of large, complex intrarenal and proximal ureteral calculi. BJU Int. doi:10.1111/j.1464-410X.2012.11352.x
Nabi G, Cook J, N’Dow J, McClinton S (2007) Outcomes of stenting after uncomplicated ureteroscopy: systematic review and meta-analysis. BMJ 334(7593):20
Makarov DV, Trock BJ, Allaf ME, Matlaga BR (2008) The effect of ureteral stent placement on post-ureteroscopy complications: a meta-analysis. Urology 71(5):796–800
Acknowledgments
We would like to acknowledge and extend our heartfelt gratitude to Prof. Dieter Hauschke, Sc.D. and Mrs. Lioudmila Bogatyreva, M.Sc. from the Institute of Medical Biometry and Medical Informatics, Freiburg, Germany, for their assistance for the statistical data analysis.
Author information
Authors and Affiliations
Corresponding author
Additional information
German Clinical Trial Register ID: DRKS00004558 (approved primary WHO register).
Rights and permissions
About this article
Cite this article
Miernik, A., Schoenthaler, M., Wilhelm, K. et al. Combined semirigid and flexible ureterorenoscopy via a large ureteral access sheath for kidney stones >2 cm: a bicentric prospective assessment. World J Urol 32, 697–702 (2014). https://doi.org/10.1007/s00345-013-1126-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00345-013-1126-z