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Indications, preferences, global practice patterns and outcomes in retrograde intrarenal surgery (RIRS) for renal stones in adults: results from a multicenter database of 6669 patients of the global FLEXible ureteroscopy Outcomes Registry (FLEXOR)

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Abstract

Purpose

To collect a multicentric database on behalf of TOWER research group to assess practice patterns and outcomes of retrograde intrarenal surgery (RIRS) for kidney stones.

Methods

Inclusion criteria: age ≥ 18 years, normal renal/calyceal system anatomy, calculi of any size, number, and position. Study period: January 2018 and August 2021. Stone-free status: absence of fragments > 2 mm, assessed post procedure according to the local protocol (KUB X-Ray and/or ultrasound or non-contrast CT scan).

Results

Twenty centers from fifteen countries enrolled 6669 patients. There were 4407 (66.2%) men. Mean age was 49.3 ± 15.59 years. Pain was the most frequent symptom indication for intervention (62.6%). 679 (10.2%) patients underwent RIRS for an incidental finding of stones. 2732 (41.0%) patients had multiple stones. Mean stone size was 10.04 ± 6.84 mm. A reusable flexible ureteroscope was used in 4803 (72.0%) procedures. A sheath-less RIRS was performed in 454 (6.8%) cases. Holmium:YAG laser was used in 4878 (73.1%) cases. A combination of dusting and fragmentation was the most common lithotripsy mode performed (64.3%). Mean operation time was 62.40 ± 17.76 min. 119 (1.8%) patients had an intraoperative injury of the ureter due to UAS insertion. Mean postoperative stay was 3.62 ± 3.47 days. At least one postoperative complication occurred in 535 (8.0%) patients. Sepsis requiring intensive care admission occurred in 84 (1.3%) patients.

Residual fragments were detected in 1445 (21.7%) patients. Among the latter, 744 (51.5%) patients required a further intervention.

Conclusion

Our database contributes real-world data to support to a better understanding of modern RIRS practice and outcomes.

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Data availability

Data are available on request from the authors.

References

  1. Assimos D, Krambeck A, Miller NL et al (2016) Surgical management of stones: American Urological Association/Endourological Society Guideline, PART I. J Urol 196:1153–1160. https://doi.org/10.1016/j.juro.2016.05.090

    Article  PubMed  Google Scholar 

  2. Skolarikos A, A. Neisius A, Petřík A, et al (2022) EAU Guidelines 2022 on Urolithiasis. https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Urolithiasis-2022_2022-03-24-142444_crip.pdf. Accessed 17 Aug 2022

  3. Inoue T, Okada S, Hamamoto S, Fujisawa M (2021) Retrograde intrarenal surgery: Past, present, and future. Investig Clin Urol 62:121–135. https://doi.org/10.4111/icu.20200526

    Article  PubMed  PubMed Central  Google Scholar 

  4. Galosi AB, Dell’Atti L, Castellani D, et al (2022) Is spinal anesthesia a safe alternative for retrograde intrarenal surgery for stone disease in daily practice? Arch Esp Urol 75:361–367. https://doi.org/10.37554/en-j.arch.esp.urol-20210525-3501-21

  5. Bosio A, Dalmasso E, Alessandria E, et al (2018) Retrograde intra-renal surgery under spinal anesthesia: the first large series. Minerva Urol Nefrol 70:333–339. https://doi.org/10.23736/S0393-2249.18.02926-0

  6. Falagario UG, Calò B, Auciello M et al (2021) Advanced ureteroscopic techniques for the management of kidney stones. Curr Opin Urol 31:58–65. https://doi.org/10.1097/MOU.0000000000000835

    Article  PubMed  Google Scholar 

  7. Sanguedolce F, Bozzini G, Chew B et al (2017) The evolving role of retrograde intrarenal surgery in the treatment of urolithiasis. Eur Urol Focus 3:46–55. https://doi.org/10.1016/j.euf.2017.04.007

    Article  PubMed  Google Scholar 

  8. Wenger DR (2012) Limitations of evidence-based medicine: the role of experience and expert opinion. J Pediatr Orthop 32(Suppl 2):S187–S192. https://doi.org/10.1097/BPO.0b013e318259f2ed

    Article  PubMed  Google Scholar 

  9. Geraghty R, Abourmarzouk O, Rai B et al (2015) Evidence for ureterorenoscopy and laser fragmentation (URSL) for large renal stones in the modern era. Curr Urol Rep 16:54. https://doi.org/10.1007/s11934-015-0529-3

    Article  PubMed  Google Scholar 

  10. García Rojo E, Teoh JY-C, Castellani D et al (2022) Real-world global outcomes of retrograde intrarenal surgery in anomalous kidneys: a high volume international multicenter study. Urology 159:41–47. https://doi.org/10.1016/j.urology.2021.10.003

    Article  PubMed  Google Scholar 

  11. Markets and markets flexible & semi-rigid ureteroscopy market by product (flexible ureteroscopes, semi-rigid ureteroscopes), application (urolithiasis, urinary stricture, kidney cancer), end user (ASCS, Hospitals), and Region (US, Canada, Asia, Europe) - Global Forecast to 2. https://www.marketsandmarkets.com/Market-Reports/flexible-semi-rigid-ureteroscopy-market-253934795.html. Accessed 24 Aug 2022

  12. Wang F, Hong Y, Yang Z, Ye L (2021) Comparison of retrograde intrarenal surgery and standard percutaneous nephrolithotomy for management of stones at ureteropelvic junction with high-grade hydronephrosis. Sci Rep 11:14050. https://doi.org/10.1038/s41598-021-93551-8

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Lim EJ, Traxer O, Madarriaga YQ et al (2022) Outcomes and lessons learnt from practice of retrograde intrarenal surgery (RIRS) in a paediatric setting of various age groups: a global study across 8 centres. World J Urol 40:1223–1229

    Article  PubMed  Google Scholar 

  14. Karakoç O, Karakeçi A, Ozan T et al (2015) Comparison of retrograde intrarenal surgery and percutaneous nephrolithotomy for the treatment of renal stones greater than 2 cm. Turkish J Urol 41:73–77. https://doi.org/10.5152/tud.2015.97957

    Article  Google Scholar 

  15. Sebaey A, Taleb AA, Elbashir S et al (2022) Flexible ureterorenoscopy (RIRS) vs. Mini- percutaneous nephrolithotomy (MINI-PCNL) for renal stones 20–30 mm a prospective randomized study. African J Urol 28:13. https://doi.org/10.1186/s12301-022-00278-7

    Article  Google Scholar 

  16. Kwon O, Lee J-M, Park J et al (2019) Influence of anesthesia methods on surgical outcomes and renal function in retrograde intrarenal stone surgery: a prospective, randomized controlled study. BMC Anesthesiol 19:239. https://doi.org/10.1186/s12871-019-0901-9

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Gadzhiev N, Oibolatov U, Kolotilov L et al (2019) Reducing kidney motion: optimizing anesthesia and combining respiratory support for retrograde intrarenal surgery: a pilot study. BMC Urol 19:61. https://doi.org/10.1186/s12894-019-0491-3

    Article  PubMed  PubMed Central  Google Scholar 

  18. Ho HC, Hughes T, Pietropaolo A et al (2020) Apnoea is not necessary for flexible ureteroscopy and lasertripsy of renal stones: a prospective study over 6 years. Cent Eur J Urol 73:193–198. https://doi.org/10.5173/ceju.2020.0100

    Article  Google Scholar 

  19. Lee YJ, Bak DJ, Chung J-W et al (2016) Is it necessary to actively remove stone fragments during retrograde intrarenal surgery? Investig Clin Urol 57:274–279. https://doi.org/10.4111/icu.2016.57.4.274

    Article  PubMed  PubMed Central  Google Scholar 

  20. Kronenberg P, Hameed BZ, Somani B (2021) Outcomes of thulium fibre laser for treatment of urinary tract stones: results of a systematic review. Curr Opin Urol 31:80–86. https://doi.org/10.1097/MOU.0000000000000853

    Article  PubMed  PubMed Central  Google Scholar 

  21. Corrales M, Sierra A, Traxer O (2022) Moses and Moses 2.0 for Laser Lithotripsy: Expectations vs. Reality. J Clin Med 11:4828

  22. Sierra Del Rio A, Corrales M, Kolvatzis M et al (2022) Thulium fiber laser’s dust for stone composition analysis: Is it enough? J Endourol In press: https://doi.org/10.1089/end.2022.0244

    Article  Google Scholar 

  23. De La Rosette J, Denstedt J, Geavlete P et al (2014) The clinical research office of the endourological society ureteroscopy global study: Indications, complications, and outcomes in 11,885 patients. J Endourol 28:131–139. https://doi.org/10.1089/end.2013.0436

    Article  PubMed  Google Scholar 

  24. Keeley FXJ (2014) Global CROES ureteroscopy registry demonstrates striking cooperation among endourologists. Eur Urol 66:110–111

    Article  PubMed  Google Scholar 

Download references

Funding

The authors did not receive support from any organization for the submitted work.

Author information

Authors and Affiliations

  1. Department of Urology, Ng Teng Fong General Hospital, Singapore, Singapore

    Vineet Gauhar, Heng Chin Tiong & Sarvajit Biligere

  2. Department of Urology, University of British Columbia, Vancouver, Canada

    Ben Hall Chew

  3. Department of Urology AP-HP, Sorbonne University, Tenon Hospital, Paris, France

    Olivier Traxer

  4. Department of Urology, University Hospital of Ghent, Ghent, Belgium

    Thomas Tailly

  5. Urology Department, Universidad Autónoma de Barcelona, Fundación PuigvertBarcelona, Spain

    Esteban Emiliani

  6. Department of Urology and Stone Center, Hara Genitourinary Hospital, Kobe City, Hyogo, Japan

    Takaaki Inoue

  7. Urology Unit, Department of Surgery, University Malaya, Kuala Lumpur, Malaysia

    Chu Ann Chai

  8. Department of Urology, University Hospital Mohammed the VIth of Marrakesh, Marrakesh, Morocco

    Mohamed Amine Lakmichi

  9. Department of Urology, Marmara University School of Medicine, Istanbul, Turkey

    Yiloren Tanidir

  10. Division of Urology, Department of Surgery, Ministry of the National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

    Saeed Bin Hamri

  11. Department of Urology, Toowoomba Hospital, University of Queensland, Brisbane, Australia

    Devang Desai

  12. Department of Urology, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal

    Anil Shrestha

  13. Medical Faculty, Mulawarman University, Abdul Wahab Sjahranie Hospital, Samarinda, Indonesia

    Boyke Soebhali

  14. Department of Urology, Penang General Hospital, Penang, Malaysia

    William Ong Lay Keat

  15. Department of Urology, Preeti Urology and Kidney Hospital, Hyderabad, Telangana, India

    Vaddi Chandra Mohan

  16. Department of Urology, Sarvodaya Healthcare, Faridabad, Haryana, India

    Tanuj Paul Bhatia

  17. Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

    Abhishek Singh

  18. Department of Urology, Apis Kidney Stone Institute, Urology Research and Day Care Center, Mangalore, Karnataka, India

    Mohamed Saleem

  19. Endourology Department, Saint-Petersburg State Medical University, Saint-Petersburg, Russia

    Dmitry Gorelov & Nariman Gadzhiev

  20. Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK

    Amelia Pietropaolo & Bhaskar Kumar Somani

  21. Urology Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti Di Ancona, Università Politecnica Delle Marche, Via Conca 71, 60126, Ancona, Italy

    Andrea Benedetto Galosi & Daniele Castellani

  22. Department of Urology, Asian Institute of Nephrology & Urology, Irram Manzil Colony, Hyderabad, Telangana, India

    Deepak Ragoori

  23. S. H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China

    Jeremy Yuen-Chun Teoh

Authors
  1. Vineet Gauhar
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  2. Ben Hall Chew
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  3. Olivier Traxer
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  7. Heng Chin Tiong
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  19. Abhishek Singh
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  20. Mohamed Saleem
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  26. Jeremy Yuen-Chun Teoh
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  27. Bhaskar Kumar Somani
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  28. Daniele Castellani
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Contributions

Conception and design: VG. Acquisition of data: DC, VG, AP, EE, BHC, TT, TI, HCT, MAL, YT, SBH, DD, SB, AS, BS, VCM, TPB, AS, MS, DG, NG, DR. Statistical analysis: CAC, WOLK, JY-CT. Drafting of the manuscript: VG, DC. Critical revision for important intellectual content: OT, JY-CT, BKS, ABG. All authors participated in manuscript writing, review, and approval of the final version of the manuscript for submission.

Corresponding author

Correspondence to Daniele Castellani.

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Conflict of interest

The authors have no competing interests to declare that are relevant to the content of this article.

Human and animal rights

The study was approve by the ethics board of the Asian Institute of Nephrology and Urology, Hyderabad, India (#AINU 08/2022). Each institution obtained its own ethics board approval before contributing and provided anonymized data. All patients signed informed consent to gather their anonymize data.

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Gauhar, V., Chew, B.H., Traxer, O. et al. Indications, preferences, global practice patterns and outcomes in retrograde intrarenal surgery (RIRS) for renal stones in adults: results from a multicenter database of 6669 patients of the global FLEXible ureteroscopy Outcomes Registry (FLEXOR). World J Urol 41, 567–574 (2023). https://doi.org/10.1007/s00345-022-04257-z

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