比較微創雙鏡聯合手術與軟式輸尿管鏡手術之結果

潘思穎、謝博帆、王又德、黃志平、張兆祥

中國醫藥大學附設醫院 泌尿部

Comparison of Surgical Outcomes between Ultramini-Endoscopic Combined

Intrarenal Surgery and Retrograde Intrarenal Surgery

Szu-Ying Pan, Po-Fan Hsieh, Yu-De Wang, Chi-Ping Huang, Chao-Hsiang Chang

Department of Urology, China Medical University Hospital, Taichung, Taiwan

Purpose: This study aims to investigate the efficacy and safety of ultramini-endoscopic combined intrarenal surgery(ultramini-ECIRS) using 12Fr percutaneous sheath for the removal of complex renal stones. Furthermore, compare surgical outcomes with retrograde intrarenal surgery (RIRS).

Materials and Methods: We retrospectively reviewed the patients with multiple renal or ureteral stones who underwent ultramini-ECIRS or RIRS between May 2020 and March 2022 in a tertiary referral medical center. This study was approved by the Ethics Committee of China Medical University Hospital with IRB number. The inclusion criteria were patients above 18 years old, multiple renal or ureteral stones detected by computed tomography (CT) or plain abdominal radiograph (KUB). Those patients with severe renal anatomic anomalies, preoperatively treated by ESWL, RIRS, PCNL within 1 month, severely compromised cardiopulmonary function, uncontrolled urinary tract infection, or uncontrolled coagulopathy were excluded from this study. Besides, we also excluded tiny renal stone which measured ≤2 mm on CT or  stone can not be assesed by image before or after operation.

All clinical information from all patients was well collected including age, sex, body mass index(BMI), ASA Physical Status Classification System (ASA), and medical history. Pre-operative KUB or CT was reviewed by two urologists and the stone burden was assessed by means of stone area, maximal stone length, and summation of stone length. Peri-operative laboratory examinations including complete blood count, blood biochemistry test, urine analysis, urine culture were recorded. Adequate antibiotic treatment was complete according to the culture sensitivity. Otherwise prophylactic antibiotics were administered 30 minutes before surgery.

Postoperative evaluations and data analysis: the day after surgery, all patients underwent routine examination including complete blood count, blood biochemistry test, and KUB or CT during removal of PCN by Radiologist. We evaluated final stone free rate(SFR) by CT or KUB. The Stone free status was defined as residual fragments < 4mm. Ancillary procedures were conducted for patients with remnant stones above 4mm. Perioperative complications were recorded according to Clavien-Dindo classification.

Statistic analysis was conducted using SAS with assistance of statistic center at China medical university.

Results: 48 and 36 patients were collected in ultramini-ECIRS and RIRS groups respectively. There is no significant differences in BMI, stone laterality, number of stones, existence of UPJ stone, low calyx stone and ureteral stone. There is also no significant differences between two groups in pre-operation Hb level, pre-op and post op renal function, blood loss, even ASA. However, in terms of ureteral stricture, 23(47.9%) in Ultramini-ECIRS group and 7(19.4%) in RIRS group were showed with significant differences. Besides, Ultramini-ECIRS group showed larger Stone burden(272.5±254.5vs167.1±137.5, P=0.03), higher stone reduction rate(95.2±19.6%,P<0.001) and stone free rate(p<0.001) with longer postoperative hospitalization(5.60±5.16 vs 2.17±1.98, P<0.001) higher Hb decrease  (1.60±2.72 vs 0.52±0.62, P=0.02) but no more operation complication  Clavien dindol(p=0.43).

Conclusion:

In patients with larger stone burden even ureteral stricture, utramini-endoscopic combined intrarenal surgery(ultramini-ECIRS) outperform retrograde intrarenal surgery (RIRS) in final stone free rate with no more operation complication rate.