Retrograde Intra Renal Surgery efficient in Large Kidney Stone management



Chandigarh, March 26, 2020 :

Dr Rajinder Yadav

A clinical study was recently conducted by Dr Rajinder Yadav, Director, Department of Urology, Fortis Hospital, Shalimar Bagh which studied the management of kidney stones using state of the art Retrograde Intra Renal Surgery procedure (RIRS). The results – based on the empirical evidence of 274 patients – showed that RIRS procedure is feasible in management of large stone burden like partial and complete staghorn stones with minimal complicacy and morbidity.

This is the first of its kind global study to be done on the efficacy of RIRS in managing kidney stones measuring 2 to 4 centimeters. This is also the only survey which studied utility of RIRS in stag horn and multiple stones. More than 98% of the patients who participated in the study opted for RIRS against PCNL. It is now considered as safe, efficacious, reproducible with minimal morbidity and faster recovery. RIRS is feasible in large stone burden like partial and complete staghorn with minimal morbidity. The study demonstrates its effectiveness in large stone burden(size>2cm.), with additional procedures required in < 3% patients.  The average time for operation through RIRS was 85 minutes. The average length of stay of patients who underwent RIRS in this study at Fortis Shalimar Bagh was 28 hours. All the patients resumed to their regular work life within 3 days of RIRS.

The study consisted of 274 patients with renal and upper ureteric stones. 185 patients were male and 89 females. 83 patients had single stones and 191 patients had multiple stones. 85 patients underwent bilateral RIRS and 189 underwent unilateral RIRS. Post operatively, check X-ray KUB (Kidney Urinary bladder region) /USG (Ultrasound) KUB were done, and patient follow-up was done in the outpatient facility and telephonically. Fragment less than 2mm, was taken as successful clearance of kidney.

Findings of the study :

  • 83 patients had a single stone, 96 patients had multiple stones, 54 patients had a partial staghorn stone and 16 patients had complete staghorn stone
  • 68 patients had less than 1-centimeter stones, 99 patients had stones which were 1 to 2 centimeters and 107 patients had stone sizes which were more than 2 centimeters
  • 87 patients had unilateral renal stones, 85 patients had bilateral renal stones, 77 patients had renal with ureteric stones and 25 patients had upper ureteric stones
  • 25 out of 274 patients were pre-stented in view of septicemia or renal impairment,
  • All 25 patients (who were pre-stented) underwent RIRS after 1 week of stenting when their general condition stabilized
  • 47 patients had renal impairment at the time of presentation, which improved in all patients and returned to normal value in 36 patients
  • 4 patients were stented in view of failed dilatation (passing ureteroscope access sheath easily over the guide wire)
  • 234 patients required no dilatation
  • 25 patients had narrowing at a single site in the ureter, 15 patients had narrowing at multiple sites which required balloon dilatation
  • Post operatively 14 patients had urinary tract infection and 7 patients had Hematuria which was managed conservatively
  • 38 (14%) out of 274 patients had stent related symptoms (dysuria or flank pain during micturition) which were settled with medications
  • Out of 274 patients, 268 patients (96%) had complete clearance of stones in the first sitting
  • 6 patients had residual stones out of which, 3 patients underwent URS, 2 patients underwent RIRS and 1 patient underwent ESWL (Extracorporeal shock wave lithotripsy); all the 6 patients were stone free after the ancillary procedure

The incidence of urinary stone disease is increasing all over the world due to environmental conditions. Additionally, detection during screening has gone up because of an improvement in health services and diagnostic tools. The management of renal stones has evolved due to technological advancements resulting in minimally invasive procedures. RIRS is feasible in large stone burden like partial and complete staghorn stones with minimal morbidity. Various studies have been done in the past where RIRS has been found comparable to percutaneous nephrolithotomy. This is with respect to stones which are 2 centimeters in size. Very few studies have been done, with respect to RIRS, for stones which were 2 to 4 centimeters. No study has been done to the best of our knowledge where RIRS has been employed to remove stag horn and multiple stones.



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