Haluk AKPINAR, MD
Associate Professor of Urology
Departments of Endourology & Robotic Surgery
Group Florence Nightingale Hospitals
Traditionally large renal stones have been treated with PNL, shockwave lithotripsy (SWL), or a combination of both and, and sometimes by an open procedure.
Currently, guidelines on urolithiasis recommend percutaneous nephrolithotomy (PCNL) as the first-line therapy for the treatment of kidney stones > 20 mm in diameter and can be considered as a gold standard. Stone-free rate following PNL is between 78% and 95%. However there are significant complications associated with this procedure, including urinary extravasation, bleeding requiring transfusion, postoperative fever, septicemia, colonic injury or pleural injury.
Due to these potential complications PNL alternative treatment modalities have driven interest. ESWL monotherapy has an overall stone-free rate (SFR) of 23% to 57%, and the rate decreases with increasing stone size. Therefore, it is not an ideal modality. Ureteroscopy in combination with ESWL has shown relatively better results with a stone-free rate of 77%, but at least after 2 sessions.
Open surgery has been almost abandoned, even for the management of very large stones. The most traditional of all these alternative modalities, has very limited indication, such as in patients with excessive morbid obesity or complex collecting systems.
Since the introduction of modern flexible ureteroscopes two decades ago, there have been remarkable technological improvements in their design. The size of scopes decreased, greater resolution obtained, field of vision extended, light transmission improved and deflection ranges increased. The smaller size of accessory instruments and very effective lithotriptors like nickel-titanium baskets and Holmium laser together with an increase in experience using them has broadened the indications for using flexible ureteroscopes.
Recently f-URS and Holmium laser lithotripsy, in other words retrograde intrarenal surgery (RIRS) started to be considered as an alternative to gold standart PCNL. Safety and efficacy of flexible ureteroscopy and laser lithotripsy in the treatment of patients with renal stones equal to or larger than 2 cm. will be reviewed in this presentation.