RETROGRADE İNTRARENAL CERRAHİ (RIRS): CERRAHİ DENEYİMİMİZ VE KLİNİK SONUÇLARIMIZ

Öz

Amaç Üriner sistem taş hastalıkları ülkemizde ve dünyada sık görülmektedir. Flexıble üreterorenoskop (flex URS) ilk defa 1964 yılında Marshall tarafından tanımlanmıştır ve ilerleyen teknoloji ile birlikte 1987 yılında cerrahi teknik olarak kılavuzlarda yerini almıştır. Endikasyonları hızla genişlemektedir. Bu çalışmamızda kliniğimizde retrograde intrarenal cerrahi (RIRS) uygulanan hastaların verileri retrospektif olarak değerlendirilmiştir. Gereç ve Yöntem Mart 2017 ile Ocak 2019 tarihleri arasında Süleyman Demirel Üniversitesi Tıp Fakültesi (SDÜ) üroloji kliniğinde RIRS yapılmış 106 hastanın demografik verileri, taş boyutları, lokalizasyonları, skopi süresi, taşsızlık oranları ve postoperatif komplikasyonlar retrospektif olarak değerlendirildi. İşlem sonrası tüm hastalar 4 hafta sonra direkt üriner sistem grafisi ve bilgisayarlı tomografi görüntüleme yöntemleriyle değerlendirildi. Bulgular RIRS uygulanan 106 hastanın (66 erkek, 40 kadın) ortanca yaşı 52 (23-73) yıl olup, ortalama taş boyutu 13,9 (7-19) mm olarak hesaplandı. Ortalama operasyon ve floroskopi süresi sırayla;74 (30-135) dakika, 62 (20-136) saniyedir. İşlem öncesinde hiçbir hastada DJ kateteri yoktu ancak tüm hastalara işlem sonunda DJ kateteri yerleştirildi ve kateter 4 hafta sonra lokal anestezi altında çekildi. On bir (%10,3) olguda üreter darlığı nedeniyle, 8(%7,5) olguda da rezidü taş nedeniyle 2. seans yapıldı.RIRS yapılan taşların 19 (%17,9) üst kalikste, 9(%8,4) orta kalikste, 40 (%37,7) alt kalikste, 38(%35,8) olguda renalpelviste olduğu değerlendirildi. Hastalarımızın % 82,1’ inde ilk seansta taşsızlık sağlandığı bulundu. İkinci seans sonrası taşsızlık oranı % 92,5 olarak tespit edildi. Hastaların ortalama yatış süreleri 1,5 gün (1-9) gündü. Beş hastada postoperatif dönemde üriner sistem enfeksiyonu gelişti. RIRS uygulanan hastalarda cerrahi ya da cerrahi dışı nedenle mortaliteye rastlanmadı. Sonuç RIRS, taş cerrahisinde etkinlik ve komplikasyonlar açısından güvenilir bir yöntemdir. Özellikle ESWL dirençli taşlarda, obez, kas iskelet deformiteli hastalarda, soliter taşlı böbrekte, gebelikte, kanama diyatezinde önemli cerrahi alternatifitir. Teknolojik ilerlemeler ile birlikte tekniğin avantajları da düşünüldüğünde ilerleyen zamanlarda daha aktif kullanılacağı ve yaygınlaşacağı görüşündeyiz.

Anahtar Kelimeler

• Böbrek taşı
• Fleksible üreterorenoskop
• Retrograde intarenal cerrahi
• Flexible ureterorenoscope
• Renal stone
• Retrograde intrarenal surgery

RETROGRADE INTRARENAL SURGERY (RIRS): OUR SURGERY EXPERIENCE AND CLINICAL RESULTS

Öz

Objective Urinary system stone diseases are common in our country and in the world. The flexible ureterorenoscope (flex URS) was first described by Marshall in 1964 and took its place in the guidelines as a surgical technique in 1987 with the advancing technology. Its indications are expanding rapidly. In this study, the data of patients who underwent retrograde intrarenal surgery (RIRS) in our clinic were evaluated retrospectively. Material and Method Demographic data, stone sizes, localizations, fluoroscopy duration, stone-free rates and postoperative complications of 106 patients who underwent RIRS in the urology clinic of Süleyman Demirel University Faculty of Medicine (SDU) between March 2017 and January 2019 were evaluated retrospectively. After the procedure, all patients were evaluated with direct urınary system graphy and computer tomography imaging methods 4 weeks later. Results The median age of 106 patients (66 males, 40 females) who underwent RIRS was 52 (23-73 years) and the mean stone size was calculated as 13.9 (7-19) mm. The mean duration of operation and fluoroscopy were respectively;74 (30- 135 minutes is 62 (20-136) seconds. None of the patients had a DJ catheter before the procedure, but a DJ catheter was placed in all patients at the end of the procedure and the catheter was removed under local anesthesia 4 weeks later. A second session was performed in 11 (10.3%) cases due to ureteral stenosis and in 8 (7.5%) cases because of residual stones. calyx, 40 (37.7%) lower calyx, 38 (35.8%) cases were found in the renal pelvis. It was found that 82.1% of our patients were stone-free in the first session. After the second session, the stone-free rate was 92.5%. Conclusion RIRS is a reliable method in terms of efficacy and complications in stone surgery. It is an important surgical alternative especially in ESWL resistant stones, obese patients with musculoskeletal deformities, solitary kidney stones, pregnancy and bleeding diathesis. Considering the advantages of the technique together with the technological advances, we think that it will be used more actively and become widespread in the future.

Anahtar Kelimeler

• Flexible ureterorenoscope
• Renal stone
• Retrograde intrarenal surgery

Kaynakça

1. 1. Stamatelou KK, Francis ME, Jones CA, Nyberg LM, Curhan GC. Time trends in reported prevalence of kidney stones in the United States:1976-1994. KidneyInt 2003; 63: 1817-23
2. 2. Akinci M, Esen T, Tellaloğlu S. Urinary stone disease in Turkey: an update depidemiological study. EurUrol 1991; 20: 200-3
3. 3. Türk C, Knoll T, Petrik A, Sarica K, Straub M, Seitz C. Guidelines on urolithiasis, European association of urology, (2011).
4. 4. Öbek C, Önal B, Kantay K, Kalkan M, Yalcin V, Öner AG, et al. The efficacy of extracorporeal shock wave lithotripsy for isolated lower pole calculi compared with isolated middle and upper caliceal calculi. The Journal of urology. 2001;166(6):2081-5.
5. 5. Pearle MS, Lingeman JE, Leveillee R, Kuo R, Preminger GM, Nadler RB, et al. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. The Journal of urology. 2005;173(6):2005-9.
6. 6. Marshall VF. Fiber optics in urology. The Journal of urology. 1964;91(1):110-4.
7. 7. Preminger GM, Tiselius HG, Assimos DG, Alken P, Buck AC, Gallucci M, et al. American Urological Association Education and Research, Inc; European Association of Urology. 2007 Guideline for the management of ureteralcalculi. EurUrol 2007; 52: 1610-31
8. 8. Wong MY. Flexibleureteroscopy is the ideal choicetomanage a 1.5 cm diameterlower-polestone. J Endourol 2008;22:1845- 1846

9. 9. Akpinar H, Tüfek İ, Gürtuğ A, Kural AR. Üst üriner sistem hastalıklarının tanı ve tedavisinde fleksibil üreteroskopi. Türk Üroloji Dergisi/Turkish Journal of Urology. 2003;29(4):454-9.
10. 10. Preminger GM. Management of lower polerenalcalculi: shock wave lithotripsy versus percutaneous nephrolithotomy versus flexible ureteroscopy. UrolRes 2006;34:108- 111.
11. 11. Grasso M, Ficazzola M. Retrograde ureteropyeloscopy for lower polecalicealcalculi. J Urology 1999;162:1904-1908
12. 12. De S, Autorino R, Kim FJ, Zargar H, Laydner H, Balsamo R, et al. Percutaneous nephrolithotomy versus retrograde ıntrarenal surgery: asystematic review and meta-analysis. EurUrol 2015; 67:125-37.
13. 13. Nguyen TA, Belis JA. Endoscopicmanagement of urolithiasis in themorbidlyobesepatient. J Endourol.1998;12:33-35.
14. 14. Chung B, Aron M, Hegarty N, y Desay M. Ureteroscopic versus percutaneous treatment for medium size (1-2 cm) renalcalculi. J Endourol, 2008; 22: 343-6.
15. 15. Resorlu B, Unsal A, Ziypak T, Diri A, Atis G, Guven S, et al. Comparison of retrograde intrarenal surgery, shockwave lithotripsy, and percutaneous nephrolithotomy for treatment of medium-size dradiolucentrenal stones. World J Urol 2013; 31: 1581-6.
16. 16. Sorensen CM, Chandhoke PS. Is lower polecalicealanatomy predictive of extra corporeal shockwave lithotripsy success for primary lower polekidney stones? J Urol 2002;168:2377–2382
17. 17. Singh BP, Prakash J, Sankhwar SN, Dhakad U, Sankhwar PL, GoelA, et al. Retrograde intrarenal surgery extra corporeal shockwave lithotripsy for intermediate size inferior polecalculi: a prospective assessment of objective and subjective outcomes. Urology 2014; 83:1016-22.
18. 18. Martin F, Hoarau N, LebdaiS, ve ark. Impact of lower polecalculi in patients under going retrogradeintrarenal surgery. J Endourol 2014;28:141–145.
19. 19. Jessen JP, Honeck P, Knoll T, Wendt-Nordahl G. Flexible ureterorenoscopy for lower polestones: influence of the collecting system’s anatomy. J Endourol 2014;28:146–151.
20. 20. Baş O, Tuygun C, Dede O ve ark. Factor saffecting complication rates of Retro grade flexible ureterorenoscopy: analysis of 1571 procedures-a single-centerexperience. World J Urol. 2017 May;35(5):819-826.
21. 21. Geavlete P, Georgescu D, Nita G, Mirciulescu V, Cauni V. Complications of 2735 retro grade semirigidureteroscopy procedures: a single cente rexperience. J Endourol 2006; 20: 179- 85.
22. 22. Watterson JD, Girvan AR, Cook AJ, et al. Safety and efficacy of holmium: YAG laser lithotripsy in patients with bleeding diatheses. J Urology 2002;168:442-445.
23. 23. Delvecchio FC, Auge BK, Brizuela RM, et al. Assessment of stricture formation with the ureteralaccesss heath. Urology 2003;61:518-522