Presented by: Vineet Gauhar MCh, Dip URO
Ng Teng Fong General Hospital, NUHS

Introduction

Bilateral kidney stones are commonly treated as staged procedures due to concerns of sepsis and possible inadvertent bilateral kidney and ureter damage as well as inability to completely clear all stones by retrograde intra renal surgery(RIRS). However having acquired sufficient experience endourologists perform single stage same sitting bilateral RIRS (SSB-RIRS) with potential advantages of saving another operative and anesthesia intervention for patients. We analysed the outcomes, practice preferences and limitations of this surgery in a global real world setting.

Materials

 Data from adults who underwent bilateral RIRS in 21centers were retrospectively reviewed (January 2015-June 2022).

Inclusion criteria:unilateral/bilateral symptomatic bilateral stone(s) of any size/location in both kidneys,bilateral stones on follow-up with symptom/stone progression. Stone-free rate (SFR) was definesd as absence of fragments >3 mm at 3 months. Outcome Measurements and Statistical Analysis Continuous variables are presented as median and (25th-75th percentiles). Multivariable logistic regression analysis was performed to evaluate independent predictors of sepsis and bilateral SFR.

Results

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Please see tables:

1250 patients were included. Median age was 48.0 (36-61)years. 58.2% of patients were pre-stented. Median stone diameter was 10 mm on bothsides. Multiple stones were present in 45.3% and 47.9% of left and right kidneys.Surgery was stopped in 6.8% of cases. Median surgical time was 75.0 (55-90) minutes.Complications were transient fever (10.7%), fever/infection needing prolonged stay (5.5%), sepsis (2%), blood transfusion (1.3%). Bilateral and unilateral SFR was 73.0%and 17.4%, respectively. Female (OR 2.97 95% CI 1.18-7.49,p=0.02), no antibiotic prophylaxis (OR 5.99 95% CI 2.28-15.73,p<0.001), kidney anomalies (OR 5.91 95% CI1.96-17.94,p<0.001), surgical time ≥100 minutes (OR 2.86 95% CI 1.12-7.31,p=0.03)were factors associated with sepsis. Female (OR 1.88 95% CI 1.35-2.62, p<0.001),bilateral pre-stenting (OR 2.16 95% CI 1.16-7.66, p=0.04), use of high-power HL (OR1.63 95% CI 1.14-2.34, p<0.01), TFL (OR 2.50 95% CI 1.32-4.74, p<0.01) were predictors of bilateral SFR. 

Conclusion

SSB-RIRS is an effective treatment for patients with bilateral stones with a short postoperative stay and an acceptable rate of complications. Pre-stenting, the use of high-power HL and TFL, and avoiding a large stone burden are key factors to achieve a high bilateral SFR. We recommend that using prophylactic antibiotics, limiting operative time to 100 minutes, and using a UAS will help to mitigate the risk of sepsis in SSB-RIRS.Maximizing  hospital and surgeon resources, avoiding duplicate use of accessories, single operating cost and importantly one anesthesia are definite winners for advocating this procedure.

Funding

NIL

Lead Authors

Daniele Castellani, MD
Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche,

Co-Authors

Olivier Traxer, MD
Department of Urology AP-HP, Sorbonne University, Tenon Hospital,

Deepak Ragoori, MCh
Department of Urology, Asian Institute of Nephrology & Urology

Nariman Gadzhiev, MD
Department of Urology, Saint-Petersburg State University Hospital,

Yiloren Tanidir, MD
Department of Urology, School of Medicine, Marmara University

Takaaki Inoue, MD
Department of Urology, Hara Genitourinary Private Hospital, Kobe University,

Esteban Emiliani, MD
Department of Urology, Fundacion Puigvert, Autónomos University of Barcelona,

Saeed Bin Hamri, MD
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,

Mohamed Amine Lakmichi, MD
Department of Urology, University Hospital Mohammed the VIth of Marrakesh,

Chandra Mohan Vaddi, MD
Department of Urology, Preeti Urology and Kidney Hospital

Chin Tiong Heng, MD
Department of Urology, Ng Teng Fong General Hospital,

Boyke Soebhali, MD
Department of Urology, Abdul Wahab Sjahranie Hospital, Medical Faculty Mulawarman University,

Sumit More, MCh
Department of Urology, Sarvodaya Hospital and Research Centre,

Vikram Sridharan, MCh
Department of Urology, Sree Paduka Speciality Hospital

Mehmet Ilker Gökce, MD
Department of Urology, Ankara University, School of Medicine,

Azimdjon N. Tursunkulov, MD
Urology Division, AkfaMedline Hospital,

Arvind Ganpule, MCh
Department of Urology, Muļjibhai Patel Urological Hospital,

Giacomo Maria Pirola, MD
Urology Department, San Giuseppe Hospital, IRCCS Multimedica, Multimedica Group

Cemil Aydin, MD
Department of Urology, Hitit University, School of Medicine,

Ben Hall Chew, MD
Department of Urology, University of British Columbia,

Bhaskar K Somani, MD
Department of Urology, University Hospitals Southampton, NHS Trust,