10-20 MM ALT POL BÖBREK TAŞLARININ TEDAVİSİNDE RETROGRAD İNTRARENAL CERRAHİYE KARŞI MİNİ PERKÜTAN NEFROLİTOTOMİ: EĞİLİM SKORU EŞLEŞTİRMELİ BİR ANALİZ

Öz

Amaç Üroloji kılavuzlarında 10-20 mm arası alt pol taşlarında özellikle ekstrakorporal şok dalga litotripsi (SWL)'nin başarısız olduğu veya SWL'nin uygun olmadığı durumlarda endoürolojik tedaviler olan perkütan nefrolitotomi (PCNL) ve retrograd intrarenal cerrahi (RİRC) önerilmektedir. Bu çalışmada 10-20 mm arası alt pol taşlarında RİRC ile mini perkütan nefrolitotomi (m-PCNL) uygulanan hastaların sonuçlarını karşılaştırdık. Gereç ve Yöntem 2020 ile 2022 yılları arasında 10-20 mm arası alt pol böbrek taşı nedeniyle endoürolojik tedavi (RİRC veya m-PCNL) uygulanan 116’sı RİRC, 71’i m-PCNL olan toplam 187 hastanın dosyaları retrospektif olarak incelendi. Preoperatif yanlılıkları önlemek için 1:1 oranı temel alınarak eğilim skoru eşleştirmesi (propensity score-match) uygulandı. Analiz sonucuna göre RİRC uygulanan 65 hasta ve m-PCNL uygulanan 65 hasta çalışmaya dahil edildi. İki grup arasında intraoperatif (operasyon süresi, floroskopi süresi) ve postoperatif bulgular (hastane yatış süresi, hematokrit düşüşü, taşsızlık oranları ve komplikasyonlar) karşılaştırıldı. Operasyon sonrası 4 mm veya daha büyük taş saptanması klinik anlamlı rezidü olarak tanımlandı. Komplikasyonlar Clavien skorlama sistemine göre ve intraoperatif-postoperatif olarak sınıflandırıldı. Bulgular Her iki grup, demografik özellikler (yaş, cinsiyet, vücut kitle indeksi), radyografik taş karakteristikleri (taş boyutu, taş lateralitesi, taş opasitesi, ve taş dansitesi) açısından karşılaştırıldığında istatistiksel olarak anlamlı fark gözlenmedi. Operasyon süresi, floroskopi süresi, hastane yatış süresi açısından gruplar karşı- laştırıldığında, RİRC grubunda bu süreler istatistiksel olarak anlamlı derecede daha kısaydı (p<0.001). Ayrıca RİRC grubunda hematokrit miktarındaki düşüş m-PCNL grubuna göre istatistiksel olarak anlamlı derecede daha azdı (p<0.001). Postoperatif taşsızlık oranları ile intraoperatif ve postoperatif komplikasyon oranlarına bakıldığında her iki gruptaki sonuçların benzer olduğu görüldü. Sonuç RİRC operasyonu 10-20 mm arası alt pol böbrek taşlarında m-PCNL operasyonu ile benzer taşsızlık ve komplikasyon oranlarına sahip olan etkili ve başarılı bir endoürolojik tedavi alternatifidir. Bununla birlikte RİRC operasyonunun m-PCNL operasyonuna göre daha kısa operasyon, floroskopi ve hastane yatış sürelerine sahip olması ile daha az kan kaybına neden olması daha güvenilir şekilde uygulanabileceğini göstermektedir.

Anahtar Kelimeler

• Böbrek Taşı
• Mini Perkütan Nefrolitotomi
• Retrograd İntrarenal Cerrahi

RETROGRADE INTRARENAL SURGERY VS MINI-PERCUTANEUS NEPHROLITHOTOMY IN THE MANAGEMENT OF 10-20 MM LOWER POLE KIDNEY STONES: A PROPENSITY MATCHED ANALYSIS

Öz

Objective In urology guidelines, endourological treatments such as percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) are recommended for lower pole stones with a diameter of 10-20 mm, especially in cases where extracorporeal shock wave lithotripsy (SWL) fails or SWL is not appropriate. In this study, we compared the results of patients who underwent RIRS and mini percutaneous nephrolithotomy (m-PCNL) for lower pole stones with a diameter of 10-20 mm. Material and Method The data of 187 patients (116 RIRS, 71 m-PCNL) who underwent endourological treatment (RIRS or m-PCNL) for 10-20 mm lower pole kidney stones between 2020 and 2022 were retrospectively analyzed. To avoid preoperative biases, propensity score-matching was applied based on a 1:1 ratio. According to the results of the analysis, 65 patients who underwent RIRS and 65 patients who underwent m-PCNL were included in the study. Intraoperative (operation time, fluoroscopy time) and postoperative findings (hospitalization time, drop in hematocrit, stone-free rates, and complications) were compared between the two groups. Postoperative stone detection of 4 mm or larger was defined as clinically significant residue. Complications were classified according to the Clavien scoring system and as intraoperative-postoperative. Results When the two groups were compared in terms of demographic characteristics (age, gender, body mass index) and radiographic stone characteristics (stone size, stone laterality, stone opacity, and stone density), no statistically significant difference was observed. When the groups were compared in terms of operation time, fluoroscopy time and hospitalization time, these periods were statistically significantly shorter in the RIRS group (p<0.001). In addition, the decrease in the amount of hematocrit in the RIRS group was significantly less than in the m-PCNL group (p<0.001). When the postoperative stone-free rates and intraoperative and postoperative complication rates were examined, it was seen that the results in both groups were similar. Conclusion RIRS operation is an effective and successful endourological treatment alternative with stonefree rates and complication rates similar to m-PCNL operation in lower pole kidney stones between 10-20 mm. However, the fact that the RIRS operation has shorter operation, fluoroscopy and hospitalization times compared to the m-PCNL operation and causes less blood loss shows that it can be applied more reliably.

Anahtar Kelimeler

• Kidney Stone
• Mini Percutaneous Nephrolithotomy
• Retrograde Intrarenal Surgery

Kaynakça

1. 1. Scales CD, Jr, Smith AC, Hanley JM, Saigal CS. Urologic diseases in America project prevalence of kidney stones in the United States. Eur Urol. 2012;62(1):160–5.
2. 2. Schoenthaler M, Wilhelm K, Hein S, Adams F, Schlager D, Wetterauer U, et al. Ultra-mini PCNL versus flexible ureteroscopy: a matched analysis of treatment costs (endoscopes and disposables) in patients with renal stones 10-20 mm. World J Urol. 2015;33:1601-5.
3. 3. Jessen JP, Honeck P, Knoll T, Wendt-Nordahl G. Flexible Ureterorenoscopy for Lower Pole Stones: Influence of the Collecting System's Anatomy. J Endourol. 2014;28:146-51.
4. 4. Türk C, Skolarikos A, Neisius A, Petrik A, Seitz C, Thomas K. EAU guidelines on urolithiasis, EAU guidelines; Proceedings of the EAU Annual Congress Amsterdam 2020; Amsterdam, The Netherlands. 20–24 March 2020.
5. 5. Junbo L, Yugen L, Guo J, Jing H, Ruichao Y, Tao W. Retrograde Intrarenal Surgery vs. Percutaneous Nephrolithotomy vs. Extracorporeal Shock Wave Lithotripsy for Lower Pole Renal Stones 20-10 mm : A Meta-analysis and Systematic Review. Urol J. 2019 May 5;16(2):97-106.
6. 6. Kallidonis P, Adamou C, Ntasiotis P, Pietropaolo A, Somani B, Özsoy M, et al. The best treatment approach for lower calyceal stones ≤20 mm in maximal diameter: mini percutaneous nephrolithotripsy, retrograde intrarenal surgery or shock wave lithotripsy. A systematic review and meta-analysis of the literature conducted by the European Section of Uro-Technology and Young Academic Urologists. Minerva Urol Nephrol. 2021;73(6):711-23.
7. 7. Ruhayel Y, Tepeler A, Dabestani S, MacLennan S, Petřík A, Sarica K, et al. Tract Sizes in Miniaturized Percutaneous Nephrolithotomy: A Systematic Review from the European Association of Urology Urolithiasis Guidelines Panel. Eur. Urol. 2017;72:220–35.
8. 8. Van Cleynenbreugel B, Kılıç O, Akand M. Retrograde intrarenal surgery for renal stones - Part 1. Turk J Urol. 2017;43:112–21.

9. 9. Shi X, Peng Y, Li X, Wang Q, Li L, Liu M, et al. Propensity Score-Matched Analysis Comparing Retrograde Intrarenal Surgery with Percutaneous Nephrolithotomy for Large Stones in Patients with a Solitary Kidney. J Endourol. 2018;32:198–204.
10. 10. Aras B, Alkiş O, İvelik Hİ, Sevim M, Başer A. Holmium laser lithotripsy with semirigid ureterorenoscopy in treatment of upper ureteral and renal pelvis stones under spinal anesthesia. Journal of Clinical Urology. 2022;15(3):224-8.
11. 11. Thoemmes F. Propensity Score Matching in SPSS. 2012. Available at: http://arxiv.org/ftp/arxiv/papers/1201/1201.6385. pdf.
12. 12. Donaldson JF, Lardas M, Scrimgeour D, Stewart F, MacLennan S, Lam TB, et al. Systematic review and meta-analysis of the clinical effectiveness of shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy for lower-pole renal stones. Eur Urol. 2015;67:612–6.
13. 13. Bansal SS, Pawar PW, Sawant AS, Tamhankar AS, Patil SR, Kasat GV. Predictive factors for fever and sepsis following percutaneous nephrolithotomy: A review of 580 patients. Urol Ann. 2017;9:230–3.
14. 14. Li MM, Yang HM, Liu XM, Qi HG, Weng GB. Retrograde intrarenal surgery vs miniaturized percutaneous nephrolithotomy to treat lower pole renal stones 1.5-2.5 cm in diameter. World J Clin Cases. 2018;6(15):931-5.
15. 15. Pillai SB, Chawla A, de la Rosette J, Laguna P, Guddeti R, Reddy SJ, et al. Super-mini percutaneous nephrolithotomy (SMP) vs retrograde intrarenal surgery (RIRS) in the management of renal calculi ≤ 2 cm: a propensity matched study. World J Urol. 2022;40(2):553-62.
16. 16. Zhang H, Hong TY, Li G, Jiang N, Hu C, Cui X, et al. Comparison of the Efficacy of Ultra-Mini PCNL, Flexible Ureteroscopy, and Shock Wave Lithotripsy on the Treatment of 1-2 cm Lower Pole Renal Calculi. Urol Int. 2019;102(2):153-9.
17. 17. Coskun A, Eryildirim B, Sarica K, Çamur E, Can U, Saglam E. Comparison of Mini Percutaneous Nephrolithotomy (Mini PCNL) and Retrograde Intrarenal Surgery (RIRS) for the Minimal Invasive Management of Lower Caliceal Stones. Urol J. 2021;18(5):485-90.
18. 18. Akbulut F, Kucuktopcu O, Kandemir E, Sonmezay E, Simsek A, Ozgor F, et al. Comparison of flexible ureterorenoscopy and mini- percutaneous nephrolithotomy in treatment of lower calyceal stones smaller than 2 cm. Ren Fail. 2016;38(1):163-7.
19. 19. Kumar A, Kumar N, Vasudeva P, Kumar Jha S, Kumar R, Singh H. A prospective, randomized comparison of shock wave lithotripsy, retrograde intrarenal surgery and miniperc for treatment of 1 to 2 cm radiolucent lower calyceal renal calculi: a single center experience. J Urol. 2015;193(1):160-4.
20. 20. Bozzini G, Verze P, Arcaniolo D, Dal Piaz O, Buffi NM, Guazzoni G, et al. A prospective randomized comparison among SWL, PCNL and RIRS for lower calyceal stones less than 2 cm: a multicenter experience: A better understanding on the treatment options for lower pole stones. World J Urol. 2017;35(12):1967-75.
21. 21. Cabrera JD, Manzo BO, Torres JE, Vicentini FC, Sánchez HM, Rojas EA, et al. Mini-percutaneous nephrolithotomy versus retrograde intrarenal surgery for the treatment of 10-20 mm lower pole renal stones: a systematic review and meta-analysis. World J Urol. 2020;38(10):2621-8.
22. 22. Gao XS, Liao BH, Chen YT, Feng SJ, Gao R, Luo DY, et al. Different Tract Sizes of Miniaturized Percutaneous Nephrolithotomy Versus Retrograde Intrarenal Surgery: A Systematic Review and Meta-Analysis. J Endourol. 2017;31(11):1101-10.