Jung HD. et al., 2022: The First 100 Cases of Endoscopic Combined Intrarenal Surgery in Korea: Matched Cohort Analyses versus Shock-Wave Lithotripsy.
Jung HD, Moon YJ, Almujalhem AJ, Alqahtani AA, Alkhureeb MA, Lee JY.
Department of Urology, Wonkwang University Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea.
Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
Department of Urology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait.
Department of Urology, Asir Central Hospital, Abha, Saudi Arabia.
Department of Urology, Najran University, Najran, Saudi Arabia.
Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea.
Purpose: This study presents our initial experience with endoscopic combined intrarenal surgery (ECIRS) for large renal stones and compares the results of a propensity score-matched cohort of patients undergoing shock-wave lithotripsy (SWL).
Materials and methods: A total of 100 adults underwent ECIRS for renal stones between August 2017 and January 2019. For comparison, 2172 patients who underwent a first session of SWL between January 2005 and May 2018 were included in the SWL cohort. Propensity score matching was performed using maximal stone length (MSL), mean stone density (MSD), and stone heterogeneity index (SHI) scores. Stone-free rate (SFR) and success rate were compared between ECIRS and SWL.
Results: In the ECIRS group, the mean MSL, mean MSD, and mean SHI were 28.7±15.2 mm, 1013.9±360.0 Hounsfield units (HU), 209.4±104.0 HU, respectively. The SFR was 70%, and the success rate was 82.0% in this group. Although the ECIRS group had larger, harder, and more homogeneous stones than the SWL group, ECIRS showed a higher SFR and success rate than SWL. After propensity-score matching, SFR and success rate remained higher with ECIRS than with SWL (both, p<0.001). In multivariate logistic regression, smaller stone size [odds ratio (OR): 0.947, 95% confidence interval (CI): 0.913-0.979, p=0.002] and lower Seoul National University Renal Stone Complexity score (OR: 0.759, 95% CI: 0.610-0.935, p=0.011) were independent predictors of successful ECIRS.
Conclusion: ECIRS showed a higher SFR and success rate than SWL for large renal stones. Smaller stone size and lower complexity of stones were associated with a higher likelihood of successful ECIRS.
Yonsei Med J. 2022 May;63(5):440-445. doi: 10.3349/ymj.2022.63.5.440. PMID: 35512746. FREE ARTICLE
Results are to be expected with what we know about SWL and ECIRS:
Before and after propensity score matching the SFR (mm at 3 months after, measured by plain X-ray) and success rate (no residual stone or an asymptomatic residual of ≤3 mm at 3 months, and no need for additional treatment during 3 months) were better in the ECIRS group (Table)
Complication rates are not given.
In the present paper “successful treatment was defined as no residual stone (stone free) or a clinically insignificant, asymptomatic residual fragment with a maximum diameter of 3 mm at 3 months after treatment (measured by plain X-ray), as well as the lack of need for additional treatment during 3 months of follow-up.”
With ESWL residual stones were historically justified because repeated treatments were possible and the procedure was non-invasive compared to open surgery. Nowadays residual stones are accepted even though the justification does not apply to ECIRS.
The differentiation between SFR and success rate just helps to hide the fact that ECIRS is better but not good.