178 Central European Journal of Urology ORIGINAL PAPER UROLITHIASIS Simultaneous and synchronous bilateral endoscopic treatment of urolithiasis: a multicentric study Oriol Angerri1, Olga Mayordomo1, Andres Koey Kanashiro1, Felix Millan-Rodriguez1, Francisco Maria Sanchez-Martin1, Sung-Yo Cho2, Eran Schreter3, Mario Sofer3, Saeed Bin-Hamri4,5, Ahmed Alasker4, Yiloren Tanidir6, Tarik Emre Sener6, Panagiotis Kalidonis7,8, Joan Palou-Redorta1, Esteban Emiliani5,7,9 1 Department of Urology, Fundació Puigvert, Universitat Autonoma de Barcelona, Barcelona, Spain 2 Department of Urology, Seoul Metropolitan Government – Seoul National University (SMG-SNU) Boramae Medical Center, South Korea 3 Tel-Aviv Sourasky Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel 4 Department of Urology, King Abdulaziz National Guard Hospital, Riyadh, Saudi Arabia 5 PETRA group 6 Department of Endourology and Stones, Marmara University, Istanbul, Turkey 7 ESUT-YAU endourology working group 8 Department of Urology, University of Patras, Patras, Greece 9 Fundacion Puigvert, Universidad Autonoma De Barcelona, Department of Urology, Barcelona, Spain Citation: Angerri O, Mayordomo O, Kanashiro AK, et al. Simultaneous and synchronous bilateral endoscopic treatment of urolithiasis. A multicentric study. Cent European J Urol. 2019; 72: 178-182. Article history Introduction The general prevalence of bilateral urolithiasis has risen to 15% and bilateral non-simulta- Submitted: Jan. 21, 2019 neous treatment has been reported to have good outcomes. The objective of this study was to evaluate Accepted: May 28, 2019 Published online: May 30, the effectiveness and safety of simultaneous bilateral endoscopic surgery (SBES). 2019 Material and methods An international multicenter analysis was performed between May 2015 and December 2017. All patients with bilateral stone disease that underwent SBES were included. Patients were treated under general anesthesia in either the supine or lithotomy position. Demographic, clinical, intraoperative and postoperative data were analyzed. Results A total of 47 patients were included. Mean age was 53.8 years and 70% of the patients were males. The mean American Society of Anesthesiology (ASA) score was 2. The mean diameter of right- and left-sided stones was 29.43 mm (2–83 mm) and 31.15 (4–102 mm), respectively. Staghorn stones were treated in 18 cases (8 right-sided and 10 left-sided), four of them were defined as complete staghorn. The procedures Corresponding author performed were 42 cases of bilateral URS and PCNL and ureteroscopy. Additionally, 5 bilateral flexible ure- Esteban Emiliani teroscopy (fURS) cases were described. Intraoperative complications occurred in five patients: four of them Fundacion Puigvert were classified as Clavien-Dindo (CD) I and one as CD II. Postoperatively, there were two cases with CD I, Universidad Autonoma De 6 with CD II and one CD IIIa. Barcelona The stone-free status was 70%. Residual stones (30%) were detected only on the side treated for high-volume Department of Urology Carrer Cartagena 340-350 (complete) staghorn calculi. Barcelona, Spain Conclusions SBES is a feasible, effective and safe procedure. It may potentially avoid repeated anesthetic emiliani@gmail.com sessions as needed for staged procedures and reduce the length of patients' hospital stay. Key Words: bilateral ‹› endoscopy ‹› PCNL ‹› simultaneous ‹› stones ‹› ureteroscopy INTRODUCTION that significantly affect the quality of life of patients. The incidence of urolithiasis ranges from 5% to 9% Urolithiasis is a recurrent disease that is increasing in Europe and from 7% to 13% in North America in frequency owing to lifestyle and dietary habits [1, 2]. The general prevalence of bilateral urolithia- Cent European J Urol. 2019; 72: 178-182 doi: 10.5173/ceju.2019.1862 179 Central European Journal of Urology sis among this patient population has risen to 15%. The mean diameter for renal stones was 29.43 mm The increasing incidence of bilateral disease poses (2–83 mm) for the right side and 31.15 (4–102 mm) treatment challenges, bearing in mind the goals of for the left. Eighteen cases were described as par- reducing surgical morbidity and minimizing costs. tial staghorn (eight in the right kidney and ten The treatment of bilateral urolithiasis has accord- in the left) and four patients had complete stag- ingly become a hot topic of discussion among urolo- horn stones. The mean size of ureteral stones was gists. Many publications have reviewed the safety 36.6 mm and 29 mm for the right and left side re- and feasibility of bilateral endourological manage- spectively. ment of stones by means of bilateral non-simultane- The procedures performed were 47 of SBES shown ous, same-session procedures (BNS), including renal in Table 2. All patients were placed in a supine po- surgical approaches: retrograde intrarenal surgery sition. The procedures included 5 bilateral flexible (RIRS), percutaneous nephrolithotomy (PCNL), ureteroscopies and 42 PCNL with contralateral ure- and endoscopic combined approach (ECIRS) as teroscopy (in 12 cases the PCNL started as ECIRS well as ureteral semirigid ureteroscopic lithotripsy followed by a contralateral ureteroscopy while the (URSL) and flexible ureteral ureteroscopic litho- PCNL was in process). Mean operative time was tripsy (fURSL). These studies have reported good 140 min (49–240 min) and mean hospital stay, results and complication rates comparable to those 3.3 days (1–15 days). achieved with unilateral treatments [3, 4]. Reports Intraoperative complications were identified in five on simultaneous treatment, by two surgeons in tan- patients. Four were classified as Clavien-Dindo (CD) dem, each of them approaching one of the affected I (one renal mucosal injury due to accidental rip-off urinary systems, are limited. The aim of this study of the laser fiber, a gluteal burn, hypothermia and was to further extend the assessment of feasibility, a PCNL liver puncture that did not require any ad- effectiveness, and safety of SBES endoscopic man- ditional treatment) and one as CD II (bleeding that agement of urolithiasis. later required a transfusion). In 15 cases an intra- operative grade I ureteral injury was described. MATERIAL AND METHODS The median blood loss was 46.8 ml (preoperative Hb: 13.36 g/dl; postoperative Hb: 12 g/dl). A multicenter study involving six countries with se- nior endourolgic surgeons was performed. Records of all consecutive patients who underwent SBES en- Table 1. Demographics doscopic treatment between May 2015 and Decem- Patients n = 47 ber 2017 were retrospectively reviewed. Exclusion criteria included active UTI and infectious stones Gender, n (%) Male 33 (70) (diagnosed in a previous surgery with stone analysis Female 14 (30) and clinical suspicion including stone appearance). Age, median, years 55 (16–80) Demographic data and characteristics of individual cases were collected, whereby staghorn stones were ASA score, n (%) I 15 (31.3) subclassified as partial (occupation of <2 calyces) II 26 (54.2) or complete (defined as complete occupation of the III 6 (12.5) calyceal system). IV 1 (2.1) Evaluation of surgical procedures included the BMI, mean, CI 95% 26.1 (23.52–28.79) patient's position, the procedure in each renal Comorbidities, n (%) unit, median blood loss and exit strategies. Intra- Hypertension 29 (60.4) and postoperative complications were recorded Diabetes 15 (31.3) using the specific Clavien-Dindo classification for Positive Urine culture, n (%) 11 (22.9) PNCL [7]. Stone-free rates were evaluated at Previous Antibiotics, n (%) 42 (87.5) 1 month follow-up. Single linear stone size, mean mm Kidney: Right/Left 29.4 (2–8 3) / 31.1 (4–102) RESULTS Ureter: Right/Left 36.6 (2–54) / 29 (4–50) Staghorn, n (%) 22 (45) The records of 47 patients, with 94 treated kidneys, Partial 18 (37.5) were reviewed (Table 1). Of these, 70% were males; Complete 4 (8.3) the mean age was 53.8 years and the median Ameri- Preoperative GFR, mean, ml/min/173 cm 87 (26–190) can Society of Anesthesiology (ASA) classification ASA – American Society of Anesthesiology; BMI – body mass index; score was 2. GFR – glomerular filtration rate. 180 Central European Journal of Urology Table 2. Summary of surgical interventions Postoperative complications (Table 3) occurred in nine patients: two CD I (a cutaneous rash and Patients n = 47 a case of auto-limited hematuria), six CD II (one Operative time, mean, min 140 (49–240) transfusion and five patients with fever, one of whom Positioning, n (%) had sepsis with candidemia), and one CD IIIa (place- Lithotomy 15 (31) Supine Valdivia position 14 (29.7) ment of a nephrostomy tube due to acute double J Modified supine Valdivia-Galdakao position 19 (40) obstruction after URS without posterior ureteral Procedure combination, n (%) damage). Mean postoperative glomerular filtration PCNL with contralateral ureteroscopy 42 (89%) rate (GFR) reduction of 2 ml/min/173 cm was not Bilateral ureteroscopy 5 (11%) statistically significant (Tables 1, 2, 3). Ureteral access sheath, n (%) During the course of the first month of follow-up, Right/ Left 24/25 (51.1/44.7) three patients presented to the emergency room Energy Source, right/left, n (%) with fever; two were treated with ambulatory oral Laser 20/22 (41.7/45.8) Pneumatic 4/2 (8.3/4.2) antibiotics and one was readmitted for IV treatment Combined (US+PN) 11/11 (22.9/22.9) with fluconazole. One patient was readmitted owing Basket removal 2/2 (4.2/4.2) to gastrointestinal bleeding with no correlation to Exit strategy, n (%) his urological process. The stone-free rate (SFR), de- JJ stent fined as the absence of stones, was 70% as assessed URS/RIRS 31 (65.9) PCNL 32 (68) by CT-KUB; the remaining 30% of patients had Nephrostomy tube high-volume staghorn stones preoperatively, with PCNL 17 (36.2) unilateral residual fragments. Instrument Damage, n (%) 2 (4.2) PCNL – percutaneous nephrolithotomy; URS – ureteroscopy; RIRS – retrograde DISCUSSION intrarenal surgery Management of bilateral urolithiasis is challenging and complex. In order to reduce patient's hospital Table 3. Outcomes and postoperative complications stay, loss of work days, repeated anesthesia sessions and possibly costs, BNS and SBES interventions has Patients n = 47 been attempted [4, 6]. However, reports on simulta- Postoperative GFR, mean, ml/min/173 cm 85 (26–178.4) neous treatment, by two surgeons in tandem, each Postoperative Hb decrease, g/dL 1.3 of them approaching one of the affected urinary sys- Hospital stay, median, days 3 (1–15) tems, are limited. To our knowledge the first series Complications, Clavien Dindo (CD), n (%) of bilateral simultaneous treatment was reported by Intraoperative 5 (10) Fever –– Chung et al. who performed simultaneous bilateral Hematuria 1 (2.1) endoscopic surgery (SBES), RIRS in four patients Blood Transfusion (CDII) 1 (2.1) with significant comorbidities. The procedures were Other 4 (8.5) CD I 4 (8.5) performed by two surgeons operating simultane- Postoperative 9 (19.1) ously in tandem resulting in initial proof of feasibil- Fever 5 (10.6) ity and safety. Then Giusti et al. described a series Hematuria 2 (4.2) Blood transfusion 1 (2.1) of SBES with PCNL and RIRS [5, 6]. As such, paral- Other 2 (4.2) leling with Chung et al. [6] and Giusti et al. [8] de- CDI 1 (2.1) scriptions, our study represents the first large mul- CDII –– CDIII 1 (2.1) ticenter series of this approach, although a number Follow up 1 mo of studies have described bilateral, same-session Fever 3 (6.3) (but not synchronous and simultaneous) surgery, Other 1 (2.1) including RIRS and PCNL. Stone Free Rate (%) 70 The profile of patients potentially eligible for BNS GFR – glomerular filtration rate; Hb – hemoglobin was defined by Williams and Hoenig [9]. These au- thors stated that surgery on the contralateral kid- ney should not proceed in patients in whom the first A double J stent was inserted after the procedure surgery had resulted in a fall in hemoglobin (Hb) in 46 patients (i.e., only one remained tubeless). of >3 g/dL, an operative time of >180 min, hypoten- Seventeen patients had a postoperative nephrosto- sion, or acidosis. Also, they suggested the following my tube after a PCNL. Operative data is summa- exclusion criteria for SBES endoscopic treatment: rized in Table 2. stone burden of >1000 mm2, complex intrarenal 181 Central European Journal of Urology anatomy, age >50 years, ASA score >2, preopera- stay from 1 to 2 days. A systematic review of the bi- tive Hb <12 g/dL, and morbid obesity. In the present lateral simultaneous (i.e., same-session) ureteroscop- study, the mean BMI of patients was 27, patients ic approach by Geraghty et al reported a mean SFR with complete staghorn stones were treated, the av- of 92%, a mean operative time of 68 min and a mean erage age was 53 years, and seven patients had an hospital stay of 1.6 days. Interestingly, a comparison ASA score of 3–4, which may reflect a more typical of cases from 2003 to 2012 and from 2013 to 2016 spectrum of patients with bilateral urolithiasis. revealed that over the latter period the incidence of For unilateral PCNL, the CROES study group report- pain requiring analgesia fell from 8.3% to 2.8% and ed a transfusion rate of 5–18%, a fever rate of 10% the incidence of fever declined from 4.2% to 2.8%, and a sepsis rate of 0.9–4.7% [10, 11]. These findings possibly owing to improvement in the armamentar- are comparable to our results for SBES endoscopic ium and greater surgical expertise in high-volume treatment, with two cases of transfusion, one of sep- centers. Notably, in this review the complication rate sis, and a very similar fever rate, having into consid- was 26% whereas in another systematic review, Rai eration that some patients had high stone burdens. et al. [16] reported a 50% complication rate in ure- In this series complications were also comparable teric stone surgery. Most of the complications in the with the unilateral and bilateral surgery. In a se- Geraghty et al. study were minor, as in our series. ries of 60 patients with bilateral renal stones (mean In a series of 26 patients who underwent PCNL and stone burden of 1177 mm2) who underwent BNS bi- same-session contralateral RIRS, Mason et al. [17] lateral PCNL, Conort et al. [12] reported a mean op- reported a SFR of 92% when considering residual erating room occupation time of 188 min and a com- fragments of 4 mm or less to be acceptable, with plete stone-free rate (SFR) of 75% in one session. performance of a second-look procedure in 19%. The When grading complications using the CD classifica- stone burden was 443 mm2. Mean operative time was tion, they reported 16 patients (17%) with CD I–II, 149 min, mean hospitalization time was 2.5 days, including fever, two with CD IIIb, one with CD IVa, and Hb fell by 1.3 g/dl, these results being similar to and one with CD IVb. Similarly, in our series the those in the present series. Mason et al. reported two mean operative time was 140 min and the SFR major complications of acute renal insufficiency and reached 70%; we also had a 25% rate of minor com- clot obstruction requiring urgent stenting which, plications (CD I–II) but no cases of CD IV or V. Blood like our only CD IIIb complication (a case of acute transfusion was not necessary in any of the patients. obstruction), resolved uneventfully after catheter- In the present study, we found a reduced mean blood ization. We consider that our own lower SFR of 70% loss of only 46.8 ml and just two patients needed is to be explained by our definition of SFR as absence transfusions being comparable to the literature. Sil- of stones and by the fact that 46% of our patients verstein et al. [13] comparing BNS and asynchronous had partial or full staghorn stones, which are known PCNL for patients with bilateral stones reported to require more than one procedure and have been a similar mean blood loss in the two groups, at 357 reported to be associated with an SFR of 56.9% when and 282 ml respectively, while the transfusion rate treated in a single surgical session [11]. was also comparable, at 28.6% and 36.8% respective- In the initial report by Chung et al. of SBES RIRS ly. Further, in the study by Silverman et al., mean in four patients with significant comorbidities, three hospital stay was significantly lower in the synchro- patients needed a secondary procedure (yielding nous group, at 3.6 vs. 7.2 days, similar to our own re- a 92% SFR) but no major complications were report- sult of 3.3 days and possibly meaning that a second ed. Later, Giusti et al. [5] published a successful case hospitalization for a second surgery may be avoided. report of a PCNL and RIRS carried out in tandem When the CROES group compared unilateral and by two surgeons. These were the first five cases of BNS ureteroscopy [14] they found that patients SBES RIRS reported in the literature that inspired who underwent same-session bilateral ureteroscopy our multicenter study. and multiple stone treatments had lower stone-free This retrospective multicenter study of SBES RIRS rates, higher retreatment rates, and longer opera- reveals similar complication rates, SFR, operative tive times compared to patients who underwent ip- time, and hospital stay compared with previous se- silateral ureteroscopy and single stone treatment. ries that have investigated bilateral, same-session To our knowledge, the largest single-center series on surgery but without two surgeons operating in tan- this subject is that described by Peng et al. [15], com- dem. In our opinion one of the advantages of SBES prising 464 patients. These authors reported similar surgery is a reduction in stone burden, potentially complication rates and SFR in single-stage bilateral permitting avoidance of secondary procedures. and unilateral RIRS, at the expense of increases in A limitation of our study is the heterogeneity of the operative time from 65 to 100 min and in hospital sample, which is a consequence of the study's mul- 182 Central European Journal of Urology ticenter nature, with each center treating patients and safe. It shows comparable outcomes to other bilat- according to local protocols. eral same session and unilateral surgical series while potentially reducing the operative time and patients' CONCLUSIONS inconvenience of having multiple staged procedures. Simultaneous and synchronous bilateral endourologi- Conflicts of interest cal surgery for stone disease appeared to be a feasible The authors declare no conflicts of interest. References 1. Sorokin I, Mamoulakis C, Miyazawa K, et al. intrarenal surgery for stone disease 12. Conort P, Bah OR, Tostivint I, et al. Epidemiology of stone disease across the in patients with significant comorbidities. Simultaneous bilateral percutaneous world. World J Urol. 2017; 35: 1301-1320 J Endourol. 2006; 20: 761-765. nephrolithotomy: Series of 60 cases. Prog Urol. 2010; 20: 1194-1199. 2. Hongwei G, Xiaoqing Z, Yanqun N, et al. 7. de la Rosette JJ, Opondo D, Daels FP, Bilateral same-session ureteroscopy for et al. Categorisation of complications 13. Silverstein AD, Terranova SA, Auge BK, treatment of uretereal calculi: A systematic and validation of the Clavien score for et al. Bilateral renal calculi: assessment review and Meta-analysis. J Endourology. percutaneous nephrolithotomy. Eur of staged v synchronous percutaneous 2016; 30: 1169-1179 Urol. 2012; 62: 246-255. nephrolithotomy. J Endourol. 2004; 18: 145-151. 3. Geraghty R, Rai B, Jones P, et al. Bilateral 8. Giusti G, Proietti S, Rodríguez-Socarrás ME, Simultaneous Ureteroscopic (BS-URS) et al. Simultaneous Bilateral Endoscopic 14. Pace K., Kroczak T, Wijnstock N, et al. Same approach in the management of bilateral Surgery (SBES) for Patients with Bilateral session bilateral ureteroscopy for multiple urolithiasis is a safe and effective strategy Upper Tract Urolithiasis: Technique and stones: results from the CROES URS global in the contemporary era- evidence from Outcomes. Eur Urol. 2018; 74: 810-815. study. J Urol. 2017; 198: 130-137. a systematic review. Curr Urol Rep. 2017; 18: 11. 9. Williams SK, Hoenig DM. 15. Peng Y, Li L, Zhang W, et al. Single-Stage Synchronous bilateral percutaneous Bilateral Versus Unilateral Retrograde 4. Jones P, Dhlwayo B, Rai B, et al. Safety, nephrostolithotomy. J Endourol. 2009; Intrarenal Surgery for Management feasibility and efficacy of bilateral 23: 1707-1712. of Renal Stones: A Matched-Pair Analysis. synchronous percutaneous nephrolithotomy J Endourol. 2015; 29: 894-898. for bilateral stone disease: evidence from 10. Kamphuis GM, Baard J, Westendarp M, a systematic review. J Endourology. 2017; 31: et al. Lessons learned from the CROES 16. Rai BP, Ishii H, Jones P, et al. Bilateral 334-340. percutaneous nephrolithotomy global simultaneous ureteroscopy for bilateral study. World J Urol. 2015; 33: 223-233. stone disease: a systematic review. Can 5. Giusti G, Proietti S, Pasin L, et al. J Urol. 2016; 23: 8220-8226. Simultaneous Bilateral Endoscopic 11. Desai M, De Lisa A, Turna B, et al. Manipulation for Bilateral Renal Stones. The clinical research office of the 17. Mason BM, Koi PT, Hafron J, et al. Safety Urology. 2016; 94: 265-269. endourological society percutaneous and efficacy of synchronous percutaneous nephrolithotomy global study: staghorn nephrostolithotomy and contralateral 6. Chung SY, Chon CH, Ng CS, et al. versus nonstaghorn stones. J Endourol. ureterorenoscopy for bilateral calculi. Simultaneous bilateral retrograde 2011; 25: 1263-1268. J Endourol. 2008; 22: 889-893. 