Kiremit MC et al, 2015: Contemporary Management of Medium-Sized (10-20 mm) Renal Stones: A Retrospective Multicenter Observational Study.

Monday, 20 July 2015

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Kiremit MC, Guven S, Sarica K, Ozturk A, Buldu I, Kafkasli A, Balasar M, Istanbulluoglu O, Horuz R, Cetinel CA, Kandemir A, Albayrak S.
Department of Urology, Medical Faculty of Medipol University , Istanbul, Turkey.

Abstract

PURPOSE: To evaluate contemporary management approaches to medium-sized (10-20 mm) renal stones.
PATIENTS AND METHODS: A total of 935 patients treated for medium-sized renal stones (10-20 mm) between July 2012 and March 2014 were included in the study program. Contemporary minimally invasive approaches applied in the management of such stones were evaluated and compared.
RESULTS: The cohort consisted of 561 male (60%) and 374 female (40%) patients. Of the 935 patients with medium-sized renal calculi, 535 (57.2%) were treated with shockwave lithotripsy (SWL), 201 (21.4%) with retrograde intrarenal surgery (RIRS), 110 (11.7%) with minimally invasive percutaneous nephrolithotomy (miniperc), and the remaining 89 (11.7%) patients with micropercutaneous nephrolithotomy (microperc). In the SWL group, stones were located mostly in the pelvis (51%), while in the miniperc and microperc groups, they were located mainly in the lower pole (46%, 53%, respectively). Stone-free rates after a single session were 77.2%, 86.1%, 88.8%, and 83.6% in the SWL, RIRS, microperc, and miniperc groups, respectively. Although no serious complications (above Clavien level III) were noted in any of the groups evaluated, Clavien I to II complications were common in the miniperc group. CONCLUSION: Although SWL is the preferred treatment option for patients with medium-sized (10-20 mm) renal stones, endourologic methods also have been found to have a significant role. Relatively lower complication rates along with higher stone-free status observed with the RIRS technique compared with percutaneous approaches have made this method a valuable option in the management of such stones in recent years.

J Endourol. 2015 Mar 6. [Epub ahead of print]

Comments 1

Hans-Göran Tiselius on Monday, 20 July 2015 09:41

In this retrospective analysis of treatment results recorded in 935 patients with renal stones the authors achieved a stone-free rate of 93.5%. With the aim of getting “a completely stone-free status with limited or no morbidity” the patients were treated with various stone removing procedures. The methodology is described as “contemporary management”; an approach that could be assumed to be in accordance with the 2014 EAU guidelines. Exactly how the patients were referred to each treatment modality was, however, apparently a result of several other considerations. It is interesting to read this report because the choice of treatment modality not strictly follows any recommendations. It is obvious that “contemporary” leaves a high degree of freedom to the urologist. For stones in the size-range included in this report stones in the renal pelvis, upper and middle calyces should preferentially be treated with SWL. But of 618 patients with stones in these positions only 405 (66%) were referred to SWL. This discrepancy is most certainly the result of the urologist’s rather than the patient’s preference.
Of all patients 57.2% were primarily treated with SWL, whereas the remaining 42.8% were managed endoscopically. It is of note that following a single session of SWL, RIRS, mini-PNL or micro-PNL none of the procedures resulted in 100% stone-free patients. Not even following auxiliary procedures, repeated treatment and alternative methods were completely stone-free kidneys attained. Although the primary stone-free rate (after 1 week) was 77.2% in SWL treated patients it was only slightly better following primary endoscopic treatment (in average 86%). For the final result an un-known number of re-SWL was used in the primarily SWL treated patients but also as additional treatment in those patients who had been treated endoscopically.
One important point is that when mini-PNL was used complications were recorded in almost 22% and with micro-PNL in 7%. The complication rate following SWL was just below 5%.
Which procedure that should be chosen as first line treatment for active removal of stones from the kidney should best be decided from stone size, stone position as well as from information on the patient’s general medical condition. But it stands to reason that whichever arguments that are used for the decision, the anaesthesia-free non-invasive approach in an out-patient setting and with low risk of complications always should be taken into account.

In this retrospective analysis of treatment results recorded in 935 patients with renal stones the authors achieved a stone-free rate of 93.5%. With the aim of getting “a completely stone-free status with limited or no morbidity” the patients were treated with various stone removing procedures. The methodology is described as “contemporary management”; an approach that could be assumed to be in accordance with the 2014 EAU guidelines. Exactly how the patients were referred to each treatment modality was, however, apparently a result of several other considerations. It is interesting to read this report because the choice of treatment modality not strictly follows any recommendations. It is obvious that “contemporary” leaves a high degree of freedom to the urologist. For stones in the size-range included in this report stones in the renal pelvis, upper and middle calyces should preferentially be treated with SWL. But of 618 patients with stones in these positions only 405 (66%) were referred to SWL. This discrepancy is most certainly the result of the urologist’s rather than the patient’s preference. Of all patients 57.2% were primarily treated with SWL, whereas the remaining 42.8% were managed endoscopically. It is of note that following a single session of SWL, RIRS, mini-PNL or micro-PNL none of the procedures resulted in 100% stone-free patients. Not even following auxiliary procedures, repeated treatment and alternative methods were completely stone-free kidneys attained. Although the primary stone-free rate (after 1 week) was 77.2% in SWL treated patients it was only slightly better following primary endoscopic treatment (in average 86%). For the final result an un-known number of re-SWL was used in the primarily SWL treated patients but also as additional treatment in those patients who had been treated endoscopically. One important point is that when mini-PNL was used complications were recorded in almost 22% and with micro-PNL in 7%. The complication rate following SWL was just below 5%. Which procedure that should be chosen as first line treatment for active removal of stones from the kidney should best be decided from stone size, stone position as well as from information on the patient’s general medical condition. But it stands to reason that whichever arguments that are used for the decision, the anaesthesia-free non-invasive approach in an out-patient setting and with low risk of complications always should be taken into account.

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